TRANSPORT DELIVERY CREDIT APPLICATION
Fields marked with an asterisk (*) are required.

 

 

 

 

 

 

*Company Name:      

*Contact:           *Fed. Tax ID #: 

*Mailing Address:       *City:      *State:       *Zip: 

*Delivery Location:      *City:      *State: 

*Email Address:

*Phone #:       Fax #:       *Emergency #: 

*Are you interested in Electronic Funds Transfer?  Yes    No

*Purchase Order Required?  Yes    No

 

DELIVERY INFORMATION
 

*Delivery Hours:       *Night Delivery?  Yes    No

Directions / Special Instructions: 


*Please indicate your tank size below.  You must fill in at least one tank size.
 

 

 

TANK SIZES

 

 

TANK SIZES

FUEL TYPE

ABOVE GROUND

UNDER GROUND

FUEL TYPE

ABOVE GROUND

UNDER GROUND

Diesel (on road)

Lead Free

Diesel (off road)

Plus

Kerosene (on road)

Premium

Kerosene (off road)

Other

 

*For All Tanks
Are all tanks or drops clearly labeled to identify the product?  Yes    No

*For Off Road Tanks
Are all off road tanks labeled NON-HIGHWAY USE ONLY?  Yes    No

*For Above Ground Tanks
Does customer have pump?  Yes    No

 

*For Under Ground Tanks
UNDERGROUND STORAGE TANK PERMIT

Required by NC as of 7/1/96
(We will contact you for a photocopy)

Facility ID#:

 

Certificate #:

 

Expiration Date:

 

 

Terms of Application
Applicant(s) consents to a credit check based upon the information provided on this application for the purpose of extending credit.  It is further understood and agreed by Applicant(s) that if credit is extended to Applicant(s), the terms of such credit account will be Net 10 days or Net 30 with 2-cent premium.  Applicant(s) agrees to pay a finance charge of 1% per month which shall be added to any account not paid in full by due date.  In the event of any default, Applicant(s) agrees to pay all costs of collection including reasonable attorney’s fees if incurred.

 

 

 

 

 

 

  *I agree to the above terms.

*Name:       *Title:       *Date: 

 

For security purposes, please type in the submission code you see in the image below:

*

Please type this submission code in the box to the left.   If you have trouble reading the code, click on the audio icon to listen to the code.

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PRODUCTS & SERVICES

  • Home Heating Oil and Kerosene
  • Gasoline and Diesel Delivery
  • Above Ground Fuel Oil Tank Installation
  • Commercial and Residential Deliveries
  • Natural Gas Systems, Oil Burners, Heat Pumps
  • Fuel for Emergency Generators at hospitals, nursing homes, manufacturing plants, computer labs, etc.

We also install and service heating and air conditioning systems through our Bain Heating and Bain Air Conditioning divisions.

SERVICE AREAS

  • Randolph County, Guilford County, Forsyth County, Davidson County, and areas of Rockingham County and Alamance County
  • Greensboro, High Point, Winston-Salem, Kernersville, Summerfield, Oak Ridge, Stokesdale, Colfax, Pleasant Garden, Reidsville, Browns Summit, Gibsonville, McLeansville, Whitsett, Julian, Jamestown and surrounding areas
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