New Customer Application

New Customer Application

Completing this form will enable Ullman Oil, Inc. to register you as a New Customer. Please fill out all fields as completely as possible and hit the SUBMIT FORM Button at the end of the Application. Do NOT forget to submit the form. You will be contacted by telephone shortly after receipt of your form. Thank you for choosing Ullman Oil, Inc as your Home Heating Supplier.

Please provide the following information:

Primary Applicant

First name (required)
Last name (required)
Middle initial

Birthdate

Street address
Address (cont.)
City
State
Zip code

Years at above address

Employer
Position

Years There
Work Phone (required)

Former Employer
Years There

Home Phone (required)
Social Security #

Homeowner?	yes no
Do you Rent?	yes no

Landlord's Name

Joint Applicant

First name
Last name
Middle initial
Street address* *if different from primary applicant
Address (cont.)
City
State
Zip code
Employer
Position
Years There
Work Phone
Social Security #

Delivery Information

Do You Request?

1. Automatic Refill    yes     no
2. Budget Billing        yes    no
    (Begins 9/1 for Qualified Applicants)
3. Oil Fueled Hot Water     yes   no

Present Fuel Level     Empty 1/4 1/2 3/4 Full

Fill Pipe Location
Tank Size (Gallons)
Referred by:
Previous Supplier

Terms & Conditions-- Disclosure Statement

1. Payment is due thirty (30) days after delivery date.

2. No late payment charges will be accessed if you are on our budget plan, and are making payments at agreed upon amount and intervals.

3. During any monthly billing period, no late payment charge will be imposed if you pay the "Balance Due", as shown on your statement , within 25 days of the statement date.

4. If you choose to pay less than the "Balance Due" a late payment charge will be added to your next monthly
statement. We figure the late payment charge using a periodic rate on the "unpaid balance". There are no charges applied on the current transactions.

5. The periodic rate is 1.5 percent per month (which is an annual rate of 18 percent).

Applicant full name
Joint Applicant full name

Authorization: I certify that I am at least 18 years of age, and that I have read and agreed to all the terms and conditions indicated on the previous pages or screens, and that I have truthfully and full completed all items on this application. I understand that this offer to esatablish a credit account was made available by Ullman Oil, Inc. If my application is approved, my account will be governed by Ohio and applicable federal law. I understand that the use of the account issued in connection with this offer will constitute my acceptance of and will be subject to the terms and conditions set forth in this credit application. I understand that approval is based upon satisfying Ullman Oil, Inc.'s credit standards. I agree to be responsible for all charges related to the credit issued by Ullman Oil, Inc. pursuant to this application. I understand that the terms of my account are subject to change as provided in the credit agreement. I certify that I am at least 18 years of age, and that I have read and agreed to all the terms and conditions indicated on the previous pages or screens, and that I have truthfully and full completed all items on this application. I understand that this offer to establish a credit account was made available by Ullman Oil, Inc. If my application is approved, my account will be governed by Ohio and applicable federal law. I understand that the use of the account issued in connection with this offer will constitute my acceptance of and will be subject to the terms and conditions set forth in this credit application. I understand that approval is based upon satisfying Ullman Oil, Inc.'s credit standards. I agree to be responsible for all charges related to the credit issued by Ullman Oil, Inc. pursuant to this application. I understand that the terms of my account are subject to change as provided in the credit agreement.

I understand that I may submit my application to Ullman Oil, Inc. electronically by clicking "Submit Form". If I choose to submit this application electronically, I acknowledge that, regardless of whether I use a web browser with security features, Ullman Oil, Inc. is unable to ensure that the data will not be intercepted by third parties. I agree that Ullman Oil, Inc. is released from any claims and/or liability in the event that the data in this application is intercepted by third parties.

Please make sure you have read the terms and conditions. Do not submit more than one application. Before submitting your application, please verify all answers are correct.

Copyright 1999-2006 Ullman Oil, Inc. Last revised: December 11, 2006

Copyright 1999-2006 Ullman Oil, Inc.
Last revised: December 11, 2006