Customer Sign Up Form Order Number First Name Last Name Email Address Home Phone Cell Phone Work Phone DL State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Drives License/ID State Drivers License/ID Number Do you own or rent? * Own Rent Street Address City Home State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Address State Zip Code Length of Residence Place of Employment Date of Birth Spouse/Co-Applicant * Yes No Heat Type Heat Type Forced Hot Water Warm Air Furnace Steam Hot Water Heated by Oil? * Yes No Delivery Method * Automatic Will Call Special Delivery Instructions How did you hear about us? * How did you hear about us? Family / Friend Neighbor Search Engine Social Media Powers Oil Trucks Flier / Newspaper Other Tank Capacity (if known) Current Tank Level (if known) Fill Pipe Location Fill Pipe Location 1 2 3 4 5 6 7 8 9 10 11 12 (see diagram below) 1. The Company is hereby authorized to deliver home heating oil to the customers’ premises detailed on this agreement, and the customer agrees to purchase all of his oil requirements from the Company until this Agreement is terminated by either party by either giving the other party written notice 30 days in advance. 2. The customer is responsible for having the premises checked at least every 24 hours and to provide easy and safe access to the fill site and to report any malfunction of the heating equipment, as the Company will not be liable for damage or freeze-up resulting from the customer’s failure to report same. Customers accepted must provide the Company with a minimum 72 hours’ notice of the request for delivery. The Company will not be responsible for oil run out resulting from the customer’s failure to provide such minimum notice. 3. The customer agrees to notify the Company of any changes that may affect the fuel consumption in the premises. 4. Under no circumstances does the Company as a condition of acceptance of this Agreement undertake to accept responsibility for the functioning of maintenance of the heating system and related equipment and damages resulting from same will not be the responsibility of the Company. Any damage of property or goods stored in the vicinity of the oil tank, boiler or furnace, will not be the responsibility of the Company. 5. Unless otherwise arranged and agreed to, accounts are due and payable on receipt of delivery. Overdue accounts are subject to a service charge up to 1.5% per month (18% per annum). Any lesser amount actually charged shall be without prejudice to the Company’s right to claim at the full rate at any future time without notice. If an account becomes overdue, deliveries may be suspended or this Agreement may be cancelled without notice and the customer shall have no claim against the Company for any reasons. 6. The Company shall not be liable for failure to supply fuel oil hereunder if prevented by an act of God, strike, flood, fire, embargo, insurrection, unavoidable accident, shortage of labor or material, government decree or any other cause beyond its control or generally whenever the contract becomes impossible to perform, including shortages of crude oil or fuel oil. 7. The customer agrees to notify in writing, the Company of any changes in ownership of tenancy of the property covered by this Agreement and failing such notification shall be responsible for all fuel oil deliveries made to the said premises. 8. The price agreed upon is based on the Company’s current posted delivered price and is subject to any increase or decrease of this posted price in effect at time of delivery. 9. The Company cannot be held responsible for any damage caused as a result of disconnection of the fuel system or storage by the customer for whatever reason unless the customer has given the Company 15 days written notice of such disconnection. 10. Outside storage facilities can be subject to waxing of the product in cold temperatures. The Company will not be responsible for damages which may result from fuel oil stored outdoors. 11. This Agreement shall not be binding upon the Company until it has been accepted and approved by the Company’s Credit Department. 12. The parties have agreed that this agreement and all documents and correspondence thereunder be drafted in the English language. 13. The undersigned agrees to personally guarantee payment to the Company for product and/repair services billed to this account. 14. The customer will be responsible to pay any additional charges incurred should the account be passed to a third party collection agency for collection. 15. The account’s standing may be reported to the credit bureau. 16. Discounted price posted on delivery tickets must be paid within 7 days. 17. Budget accounts must be paid monthly according to terms of budget agreement. Budget accounts not paid will be subject to finance charges of 1.5% monthly or 18% annually if unpaid. 18. ALL BILLS MUST BE PAID WITHIN 21 DAYS OF DELIVERY DATE POSTED ON TICKET AND BEFORE NEXT OIL DELIVERY IS MADE. I hereby certify the above information to be true and complete. I authorize and consent to Powers Energy the ability to obtain and exchange credit information with any person or corporation with whom I have or propose to have financial relations. Note: THE COMPANY IS RESPONSIBLE FOR THE DELIVERY OF PRODUCT TO THE RECEIVING PIPE OR OUTLET DESIGNATED BY YOU. NEITHER THE COMPANY NOR ITS EMPLOYEES OR AGENTS, ARE OR SHALL BE LIABLE UNDER ANY CIRCUMSTANCES FOR ANY DAMAGES RESULTING FROM LEAKS OR FROM FAILURE OF THE RECEIVING TANK, ASSOCIATED PIPING, OR ANY OTHER MATTER. Upon submitting this form, you are digitally signing that you agree to the terms of agreement listed above. * I agree to the terms of the agreement.