Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Employer's Name and Address:

Social Security #

Choose one of the following options:

I Rent
I Own

How long at this address?

If at address less then one year - Previous Address

Mailing address if different then above:

Spouse's Name

Spouse's Social Security #

Spouse's Employer's Name, Address and Phone #:

If you rent: Landlord's Name and Phone #:

Please list what appliances will you be using gas for?

Delivery address (if different than contact address)

Current propane supplier:

Approximate gallons used per year used:

AS PART OF THE APPLICATION PROCESS, BLUE FLAME MAY ACCESS YOUR PERSONAL CREDIT REPORT, AND OR YOUR BUSINESS CREDIT REPORT (IF APPLYING FOR BUSINESS CREDIT).

BY AGREEING BELOW, YOU GIVE PERMISSION FOR BLUE FLAME TO ACCESS YOUR CREDIT REPORT FOR THE PURPOSE OF GRANTING AND MAINTAINING CREDIT WITH BLUE FLAME GAS.

I AGREE TO BE PLACED ON A C.O.D. BASIS AT ANY TIME IF MY CREDIT HISTORY IS DEEMED UNSATISFACTORY BY BLUE FLAME GAS CO. INC. CUSTOMERS PLACED ON C.O.D. MUST CALL TO ARRANGE A DELIVERY OF PROPANE C.O.D. ACCOUNTS MUST PAY PRIOR TO DELIVERY OR AT THE TIME OF DELIVERY.

Yes No