Credit ApplicationYou may print this credit application, fill it out, and send it by mail to Leffert Oil Company, 3216 Olympia Drive, Lafayette, IN 47909. A MS Word (.doc) version of this application is available here.Name: Soc.Sec.#: Street Address line 1: Street Address line 2: City: State: Zip: Home Phone #: Work Phone #: Employer: Position: Employer's Address line 1: Employer's Address line 2: Spouse's Name: Soc.Sec. #: Spouse's Employer: Position: Employer's Address line 1: Employer's Address line 2: Phone #: Banking Reference: Type of Account: Checking Savings Loan Bank Account Number(s): ____________________________________________________ Other Credit References: Company __________________________ Account # ______________________ Company __________________________ Account # ______________________ Company __________________________ Account # ______________________ Personal References: Name ___________________________ Relationship ______________________ Address _______________________________ Phone #: ( ) _______________ Name ___________________________ Relationship ______________________ Address _______________________________ Phone #: ( ) _______________ All credit terms as specified upon invoicing. I/We authorize the above-cited references to supply pertinent information as may be required to determine our credit capabilities. I/We agree that all past due balances may be subject to 2.00% service fee per month on the unpaid balance commencing thirty (30) days after billing. I/We shall assume all responsibility for all collection agency fees charged to creditor, attorney fees, court costs and other costs incurred while collecting the amount due. I/We have read, understand, and accept the above terms. Applicant ______________________________________________ Date ________________________ Co-Applicant ___________________________________________ Date ________________________ |