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Delivery Type/Uses:

What type of deliveries would you like?

Fuel Uses:

Applicant Information:

Your Name

Date of Birth

Phone

Current Street Address

Email

City

State

Zip

Do you rent or own?

Monthly Rent or Mortgage:

How long have you lived at the above address?

Previous Address:

Complete Previous Address:

Please enter the complete address of your previous residence.

How long did you live there?

Employment Information:

Current Employer

How long have you worked at your current employer?

Complete Employer Address:

Please give the street, city, state, and zip code of your current employer.

Employer Phone

Employer Fax

Employer's Contact Email:

Your Current Position:

What type of employee are you?

Annual Income:

Previous Employer:

Previous Employer Complete Address

Please enter the complete address: street, city, state, and zip code.

Previous Employer Position held:

Previous Employer Annual Income

Will this Account have a Co-Applicant?

Co-Applicant Information:

Co-Applicant Name

Co-Applicant Date of Birth

Co-Applicant Phone

Co-Applicant Complete Address

(if Different from Applicant)

Co-Applicant Employment Information:

Current Employer

Complete Employer Address

Please include the street, city, state, and zip code.

Employer Phone Number

Position at the Company

What type of Employee are you?

Annual Income

Applicant's Personal Reference:

Name of a Relative Not Residing with you:

Personal Reference's Complete Address

Please include the street, city, state, and zip code.

Personal Reference's Relationship to You

Previous Fuel Dealer:

Dealer's Name

Dealer's Complete Address

Please include the street, city, state, and zip code.

Dealer's Phone Number

Applicant's Financial Obligations:

Please tell us about your financial obligations.

1st - Type of Debt

1st - Creditor Name

1st - Account, Balance and Payments

Please list the account number, account balance, and monthly payment for this creditor.

2nd - Type of Debt

2nd - Creditor Name

2nd - Account, Balance and Payments

Please list the account number, account balance, and monthly payment for this creditor.

3rd - Type of Debt

3rd - Creditor Name

3rd - Account, Balance and Payments

Please list the account number, account balance, and monthly payment for this creditor.

Other Assets or Sources of Income:

Other Income Source

Amount per Month or Value

Signatures:

I authorize Robert Greene, Inc. to verify the information provided on this form as to my credit and employment history.

Applicant Signature

Please type your full name - as your electronic signature

Co-Applicant Signature

Please type your full name - as your electronic signature

Your form has been submitted. Thank You!