1General Info2Delivery/Service InformationGeneral Credit Information(items with (*) required for all propane and charge accounts)Primary ApplicantMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCellEmail* Social Security*DOB*Driver’s License*State/Exp*Place of Employment*AddressCo-ApplicantCo-ApplicantMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCellEmail Social SecurityDOBDriver’s LicenseState/ExpPlace of EmploymentAddressDelivery/Service Information (All credit approved propane accounts will be set up on automatic delivery)Delivery Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Existing Propane Appliances Furnace Boiler Space Heater Water Heater Fireplace Dryer Cooking/Stove Generator(check all that apply)Select One* Rent Owen(**SEE REVERSE SIDE FOR DEPOSIT REQUIREMENTS ON RENTAL PROPERTIES)If location is rentedName of Property Owner/LandlordAccount # if applicableLandlord PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Propane Equipment RequiredTank Size/Qty 200 lb 420 lb 330 Gallon 500 Gallon 1000 GallonEst. Gallons/YearSpecial InstructionsHomEnergy, A Division of MX Petroleum Corp. (Hereafter referred to as MX Petroleum Corp.) is responsible for the installation cost of tanks and regulators outside of the house. The customer is responsible for the cost of installation and all materials for piping from the outside of the house to the appliances inside the house along with any extra outside expenses (i.e. trenches, special piping requirements, etc.).MX Petroleum Corp. is the owner of all the tanks and regulators. Only MX Petroleum Corp. is permitted to fill or move the above-mentioned tank(s). Customer is responsible for any damages to MX Petroleum Corp.’s equipment, except for normal wear and tear.By signing below, I acknowledge I have read and agree to the full terms and conditions (including pricing) described on both sides of this agreement. I confirm that the information I have given in this application is complete and accurate. I hereby authorize the release of any required personal information to MX Petroleum Corp. for the sole purpose of verifying my credit.APPLICANT NAME*Name First Last APPLICANT SIGNATURE*Date Month Day YearCO-APPLICANT NAMECO-APPLICANT SIGNATUREDate Month Day YearTERMS & CONDITIONS* I acknowledge that I have read and understand the terms & conditions as set forth in this agreement between MX Petroleum Corp. and myself.Credit Approval/Account Set Up All propane accounts must be credit approved. An authorized agent of HomEnergy, A Division of MX Petroleum Corp. (Hereafter referred to as MX Petroleum Corp.) will use the information provided to verify credit through an outside credit reporting agency. The credit application will remain on file for the duration of your time as a customer. All information provided is for MX Petroleum Corp.’s use only and will not be shared with any outside parties. Please be advised that all credit approved propane accounts will be set up with automatic delivery. MX Petroleum Corp. reserves the right to remove your account from automatic delivery at any time if you fail to abide by the terms and conditions as set forth in this agreement. If for any reason you choose to have your account removed from automatic delivery it is required that you submit a written request to our office at 33 Depot Street Saranac Lake, NY 12983. General Terms & Conditions of Payment MX Petroleum Corp. requires payment in full within 10 days of your delivery or prior to your next delivery, WHICHEVER COMES FIRST. No deliveries (call in or automatic) of any product will be made if there is an outstanding balance owed on the account. To the extent that purchases remain unpaid beyond agreed terms; MX Petroleum Corp. will assess finance charges or interest, whichever is applicable, at the maximum rate allowable under NY State Law. Payments received will be applied to any finance charges or interest owing on the account first with any remaining credit to be applied towards aging balance. (MX Petroleum Corp. does not accrue interest upon interest). If payment is not received within 30 days from date of delivery, then you will receive written and/or verbal notice that the tanks will be picked up due to non-payment. Any costs and/or fees accrued due to tank pick up will be the responsibility of the customer. If full restitution is not made on purchases within 60 days and no other payment agreement can be reached, Seller reserves the right to charge credit card on file or perform an E.F.T. payment using your bank information to secure the balance past due on account. If this option is not available, MX Petroleum Corp. also reserves the right to proceed with collections through a 3rd party agency or take civil action against you in a court of law. Any expense accrued by MX Petroleum Corp. while attempting to collect a debt owed, including but not limited to reasonable attorney’s fees and court costs, must be reimbursed to MX Petroleum Corp. by you the customer. Lock-In Pricing/Cash Discount Terms & Conditions Customer understands that upon execution of this agreement, MX Petroleum Corp. may enter into contracts or arrangements to obtain and secure supply of the committed gallons to supply customer at the Lock-In Price. Customer acknowledges that MX Petroleum Corp. cannot predict whether the price of fuel will go up or go down and that the Lock In Price shall apply to all customer’s required gallons during term of the Lock In Pricing even if the MX Petroleum Corp. selling price is less than the Lock In Price at the time of delivery. Should customer cancel this contract or be in default prior to the completion of the Lock-In Period, MX Petroleum Corp. may assess penalties to recover MX Petroleum Corp. losses and/or legal expenses along with restocking and termination fees. A cash discount price of 10 cents per gallon off the charge price will be calculated on your delivery ticket invoice total (discount subject to change). This discount applies to both Lock-In and Non-Lock In pricing. After 10 days from the date of delivery, if payment has not been received the 10 cent per gallon discount does not apply. All budget accounts will automatically receive the cash price discount. CREDIT/DEBIT CARD PAYMENTS DO NOT RECEIVE CASH PRICING. PAYMENTS MUST BE IN FORM OF CHECK, MONEY ORDER, CASH OR ELECTRONIC FUNDS TRANSFER (E.F.T. INFORMATION AVAILABLE UPON REQUEST). Propane Tank Rental Fees for Customer/Minimum Purchase Requirements By signing this contract, you are agreeing to a minimum yearly (January 1st – December 31st) purchase requirement described below. These requirements will take effect beginning January 1st of the year following the contract date. MX Petroleum Corp. may charge a yearly tank rental fee or a delivery fee per tank. In the event a customer fails to meet the minimum purchase requirements, MX Petroleum Corp. reserves the right to charge a yearly rental fee of $100.00 per tank for the shortfall gallons. Account reviews will be in the month of January and any applicable rental fees will be billed at this time. Required Purchase Requirement □ 200 lb Tank – 50 Gallons Per Year □ 330 Gallon Tank- 350 Gallons Per Year □ 420lb Tank – 100 Gallons Per Year □ 500 Gallon Tank – 500 Gallons Per Year □ 1000 Gallon Tank – 1000 Gallons Per Year Owners/Landlords of rental properties: In the event you are the legal property owner but use the delivery location as a rental property you are responsible for notifying us of change in tenant at said location. Any deliveries made to the location without an active supply agreement on file for the current tenant will be billed to the property owner/landlord. Any unpaid product remaining in the tank at the time the tenant vacates the location will be made available for purchase to you; in the event you decide to opt out of purchasing this unpaid product MX Petroleum Corp. reserves the right to perform a pump out to recoup its costs. In the event the tenant fails to pay any balance due on his/her account resulting in the need for a tank pick up MX Petroleum Corp. will contact the property owner/landlord to allow them the opportunity to settle the debt owed and avoid tank pick up. Property owner/landlord must understand that no deliveries will be made to their property in the event their tenant owes an outstanding balance. **If you are not the legal owner of the property on which the tank is set (tenant), you are required to pay a $150 security deposit. MX Petroleum Corp. reserves the right to retain this deposit in the event of termination/default of contract** Termination/Default of Contract MX Petroleum Corp. reserves the right to terminate this contract at any time for any of the following reasons: • Fails to maintain an acceptable credit rating with MX Petroleum Corp. or is otherwise in arrears in any bill due to MX Petroleum Corp. or its service representatives; (MX Petroleum Corp. does not accept C.O.D. Propane Accounts) • Misuse and/or damage of MX Petroleum Corp. equipment • Fails to meet minimum yearly gallon purchase requirements In the event of termination of service whether requested by MX Petroleum Corp. or the customer, a pick up fee of $150.00 per delivery location plus a restocking fee of $1.00 per gallon for any product remaining in tanks at time of pick up will be charged to your account. If any of these fees apply, customer agrees to pay these fees within 10 days from date of tank pick up. NameThis field is for validation purposes and should be left unchanged.
