Customer Information

    Name
    Date of Birth (MM/DD/YY)
    Business Relationship
    ProprietorshipPartnershipCorporation
    Doing Business As (Legal Trade Name)
    Address
    Address 2
    City
    Province
    Postal Code
    City 2
    Province 2
    Postal Code 2

    (if less than 2 years at current, provide previous address as well)

    Telephone
    Fax #
    E-mail

    Please be advised that Rock Mountain Energy Ltd. sends all customer invoices and statements via email, therefore email addresses are required.
    Customers who do not have an email address may contact the office to arrange mail delivery.

    Company Officers

    Name
    Title
    Name
    Title

    Contact Names

    Purchasing
    Accts Payable
    Business Description

    Credit References

    Bank
    Branch
    Phone
    Contact

    Trade references from whom customer is buying on credit - Name and fax number Note: Credit Cards are not considered as trade references

    1.

    2.
    3.
    Annual Income
    Sources

    Product Information

    Est. Month Usage (Litres)

    Diesel
    Gas
    Lubes
    Propane

    Check those that apply:

    Cardlock #Card RequiredDelivered FuelColoured Fuel

    Credit Information

    Estimated highest 1 month purchases: $ Credit limit requested: $ Additional Information or Notes

    Payment Due

    Accounts are due in full on or before the 20th of the following month. If payment is not received on or prior to this date, penalty interest will be applied on all invoices over 30 days old, from date of invoice, at a rate of 2% per month (26.8% per annum). Rock Mountain reserves the right to suspend or alter credit terms as required.

    Authorization

    Guarantee

    The individual(s) electronically submitting this application for credit on behalf of the applicant proprietorship, partnership, or corporation noted above, if applicable, hereby individually in their individual capacities, personally, and unconditionally guarantee payment to Rock Mountain Energy Ltd. for all amounts now or hereafter owing by the above applicant for goods delivered, services rendered, and all interest accrued on any amounts past due.