Buell Fuels Credit Card Application — Adirondack Food & Fuel

Local Gas Credit Application

First Name *

Last Name *

Date of Birth *

SSN *0 / 11

Email Address *

Phone Number *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Do you own or rent? *OwnRent

Monthly Rent *

How Long? *

Employment Information

Current Employer *

How Long? *

Phone Number *

Employer Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Cards Needed

Card Information

Name on Card *

PIN *0 / 4

Electronic Funds Transfer Agreement

First Name *

Last Name *

Payer Number

Email Address *

Phone Number *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Bank Name *

Branch *

Bank Phone Number *

Bank Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Account Type *

Bank Account Number *

ABA/Bank Transit Routing Number *

Disclaimer

This authority shall remain in effect until terminated by written notice by either CUSTOMER or LOCAL GAS. Effective Date of termination will be fifteen (15) days after receipt of written notice.

Notice of termination shall in no way affect debit/credit entries initiated by LOCAL GAS prior to actual receipt of notice.

CUSTOMER agrees to be responsible for Bank's processing charge for all items. LOCAL GAS will be responsible for all costs associated with delivery of debits/credits to the CUSTOMERS bank.

All credit and other terms and requirements between CUSTOMER and BUELL remain in effect. I do certify that I have the full capacity and authority to authorize and direct.

Customer Authorization

Guidelines

As a customer of Local Gas, we need to make you aware of the following guidelines so we may best serve your 11eeds. Failure to meet terms listed below may result in Local Gas refusal to serve you.

There will be an ACH withdrawal from your checking account every Tuesday for the week prior.
There is a 2% per month charge on any unpaid balances over 30 days.
Past Due accounts will be forwarded for collection with additional fees for collection, searches, processing, and service.
Any returned ACH payments will result in a $30 chargeback fee.

By signing below, I accept the above terms and conditions and agree to pay for all purchases made by the Buell Fuels Local Gas card assigned to me. If the card is lost or stolen, I assume all responsibility until Local Gas is legally notified by me in written form, in person, or by certified mail.

I am the financially responsible party for this account.

Authorized Signature *

Title

Date *

Authorized Signature

Title

Date

Credit Card Application

Buell Fuels Buell Card

Local Gas Credit Application

Employment Information