Personal

Please fill in the information, and read our terms of agreement below prior to sending it.

Your Name (last – first – middle) (required)

Your Email (required)

Your Phone number (required)

Reason for applying

Mother’s maiden name (required)

Mailing address (street – city – state – zip) (required)

Social security number (required)

Birth Date (MM/DD/YY) (required)

Driver’s License number (required)

Delivery physical address (street – city – state – zip)

Rent or own
Rent Own 

Years at this address (required)

Employer name (required)

Employer's address (street – city – state – zip) (required)

Bank Name

Bank's Address (street – city – State – zip) (required)

Your Relative Name (required)

Your Relative Phone Number (required)

Your Message

 

Freeway Propane Charge Account Agreement

To pay the balance of my account on or before the fifteenth of the month following the date of purchase.

No Finance Charge if account paid when due.

Your account shall be subject to a Finance Charge if the account or portion thereof is not paid by the fifteenth of the month following first statement.  The Finance Charge is a “periodic rate” of 1½% per month or an Annual Percentage Rate of 18% on balances or $1.00 Minimum on amounts under ($66.66).

SELLER or BUYER may at any time terminate this charge account upon written notice to either party.

Reasonable collection or attorney fees and court costs may be charged if this agreement is referred for collections or to an attorney or collection agency.

I/We certify that the foregoing information has been supplied truthfully, accurately and voluntarily, and therefore authorize the named creditor to investigate my/our creditworthiness, credit history and financial responsibility through any credit bureau or by any other reasonable means, including direct contact with past and present creditors.  I/We also authorize banks and other financial institutions to give information to the named creditor in connection with this transaction about my/our savings and checking accounts and loans.  If credit is extended as a result of this application, I/we agree to make payment promptly in accordance with the creditor’s terms.