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

    [checkbox* authorization "By clicking "agree and submit" at the bottom of this credit application, I agree that Rock Mountain Energy Ltd. (The company) may, from time to time, give any credit and other information, including any information on this application to, or receive such information from any (a) credit bureau or reporting agency; and (b) person in connection with any dealings I have or propose to have with the Company, or the Company's authorized representative. I further agree that the Company may use that information to establish and maintain a relationship between the Company and myself and to offer me any service as permitted by law. "]

    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.