Jack F. Corse, INC.
P.O Box 300
Cambridge, Vermont 05444-0300
Phone 802-644-2749 ~ Toll Free 800-660-2749 ~ Fax 802-644-5072
(Form must be mailed or faxed as Signature is Required)
APPLICATION FOR 30 DAY CREDIT ACCOUNT
(NOTE: MUST BE CREDIT APPROVED IN ORDER TO BECOME A NEW CUSTOMER).
APPLICANT INFORMATION
NAME:________________________________________________________________
last first m
MAILING
ADDRESS:____________________________________________________________
Pob or 911 city state zip
SERVICE
ADRESS:______________________________________________________________
911 location city state zip
HOME TELEPHONE #:_________________ Cell phone # (optional) ____________________
NAME OF EMPLOYER: ________________________________________________
ADDRESS:_______________________________________________________
Pob or 911 city state zip
EMPLOYER TELEPHONE #:_____________________
**APPLICANT’S SOCIAL SECURITY #:__________________________
**APPLICANT’S SIGNATURE:___________________________________
**We, Jack F. Corse Inc., must have your social security number and signature to obtain a copy of your credit report in order
for us to consider extending credit. It also gives Jack F. Corse Inc. the right to obtain a copy of your credit report, to increase
your credit line, for the purpose of taking collection action or for other legitimate purposes associated with the account**
Business References (One, your last fuel supplier please)
_______________________________________________________________
NAME ACCOUNT TYPE TELEPHONE #
________________________________________________________________________
NAME ACCOUNT TYPE TELEPHONE #
Currently _____OWN _____RENT
Indicate which product(s) you need:
___ Fuel Oil –where is your Fill-Pipe located__________________________________
___ High Sulfur Diesel ___ 60/40 Mix ___ Bio-High Sulfur Diesel ___ Propane
___ Kerosene ___ Bio-Fuel Oil ___ K-1 (for monitor heaters) ___ Bio-Low Sulfur Diesel
___ Low Sulfur Diesel **Gasoline ___No Lead (87) ___ Mid-grade (89) ___Super (93)
DIRECTIONS TO YOUR LOCATION:_______________________________________
________________________________________________________________________
________________________________________________________________________
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