Authorization to use Credit Card for Payment Agreement
and/or Activation of Automatic delivery

 I authorize Valley Energy to use our credit card and/or activate automatic delivery effective Saturday, May 19, 2012

The following terms will apply:

1. 30-Day Accounts: Invoices are due upon receipt.
2. Smart Pay Program: Smart Pay payments are due by the 15th of each month. Smart Pay accounts that are more than three (3) months in arrears may be changed to a 30-day account without notice.
3. Automatic Delivery (if applicable) may be interrupted without notice if your account is deemed past due.
4. Termination of automatic delivery service must be made in writing or e-mail.
5. A finance charge of 1.5% (18% per annum) will be charged on all unpaid balances over 30 days.
6. Customer is liable for collection costs, attorney fees and court costs incurred by Valley Energy to collect any unpaid balance.
7. Fuel oil and/or propane, until paid in full, remains the property of Valley Energy.
8. Valley Energy has authorization to use the credit card on file for all deliveries and/or service work.
9. If tank is located inside, an inspection of the tank is mandatory for the first fill.
10. This form must be signed and received BEFORE delivery is made and/or activation of automatic delivery.

Automatic Delivery: Will Call Delivery:
Name

Account Number (if known)

Email Address