Become A New Customer

Please complete the credit application below.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile Phone

(###)

###

####

Employer's Name and Address

Social Security Number

Do you own or rent?

Own

Rent

How long have you been at this address?

If you have been at this address less than 1 year, what was your previous address?

Mailing address, if different than above

Spouse's Name

Spouse's Social Security Number

Spouse's Employer's Name, Address and Phone Number

If you rent: Landlord's Name and Phone Number

Please list what appliances you will be using gas for

Delivery address (if different than contact address)

Current propane supplier

Approximate gallons used per year

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.

Yes

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