My Maritime Become a Customer YOUR DETAILS*RequiredName* First Last Billing Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Other PhoneWork PhoneEmail Address* e-statements Get E-Statements Do you rent or own?* Rent Own Landlord Name & Phone AUTHORIZED CONTACTName First Last PhoneEmail DELIVERYSame as Billing Address Same as Billing Address Delivery Address* Street Address City State / Province / Region ZIP / Postal Code Delivery Instructions (i.e. House Color/Style, Landmarks, etc.)*Previous Supplier FUEL TYPEUntitled Oil #2 Propane K1 Off Road Diesel Heating FuelFuel Tank Size* 138 275 330 Unknown Other Fuel Pipe/Tank LocationFuel Inventory*Empty1/4 Full1/2 Full3/4 FullFullFuel Auto Delivery* Yes No Heating System* Boiler Furnace K-1 Monitor Other Hot Water Source* Oil Propane Electric Other Propane Tank Size* 60 120 240 Unknown Other *Please Specify Tank Size Is this a Maritime Energy tank?* Yes No % of Propane in tank* Propane Auto Delivery* Yes No Propane used for Boiler Furnace Hot Water Generator Fireplace Cooking Space Heater Pool Dryer MORE OPTIONSCheck all that apply Service Contract Inspection Appointment Budget EFT Payment Automatic Payment Credit Application CREDIT APPLICATIONcredit app agreement Yes No I authorize Maritime Energy to run a credit report from a National Credit Bureau to determine my credit worthiness. *By not completing the credit application it is understood that the account will be set up as a COD account until such time as a credit application is completed and approved.Social Security Number* Applicant's Date of Birth* MM slash DD slash YYYY Applicant's Employer Name* Where are you currently employed?Co-Applicant's Full Name Co-Applicant's Social Security Number Co-Applicant's Date of Birth MM slash DD slash YYYY Co-Applicant's Place of Employment Co-Applicant's Work Phone ADDITIONAL NOTESWe may collect nonpublic personal information about you from the following sources: information we receive on applications or other forms; information about your transactions with us; and information we receive from a consumer reporting agency. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. We restrict access to nonpublic information about you to those employees who need to know that information to provide products or service to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Maritime Energy reserves the right to refuse an account based upon information obtained through a credit report. Maritime Energy reserves the right to assess a finance charge computed by a periodic rate of 1½% per month, which is an Annual Percentage Rate of 18%, on amounts past due 30 days or more, as well as any additional collection fees.
