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Please Complete This Application Fully.
If You Have Any Difficulties In Doing So Please Do Not Hesitate To Contact Us.

Click to Download PDF File

Last Name*
First Name*
Middle Initial
Birth-date*
Social Security #*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer*
Work Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Spouse Last Name
Spouse First Name
Middle Initial
Birth-date
Social Security #
Employer
DBA*
Federal ID #*
Ownership*
- Sole Owner
- Partnership
- Corporation
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Principal Name*
Principal Title*
Principal SS#*
Principal Name
Principal Title
Principal SS#
Credit References:
Name:*
Address:*
Phone Number:*
Name:
Address:
Phone Number:
Name:
Address:
Phone Number:
Bank References
Checking - Bank*
Checking - Account #*
Checking - Branch*
Savings - Bank*
Savings - Account #*
Savings - Branch*
Type of Account*
- Cardlock
- Commercial On-Site Deliveries
- Home Heating Fuel
It is understood by the applicant that the monthly Finance Charge will be 1.5% ( 18% per year computed monthly ) of the outstanding balance. Finance Charges will be imposed on this account by applying the periodic rate shown above to any previous balance.
You promise to pay this account in full within 15 days of purchase. If, however, this account is not paid as agreed, you agree to pay in addition to the amount owed, the (interest charge) stated. You will be responsible for any and all collection agency fees up to 50% of the amount placed with the collection agency. In the event we seek legal action, you will also be responsible for any and all fees associated with court costs, garnishment and/or attorney fees.

For value received, each and every party who signs this agreement or becomes liable either now or hereafter for the payment of this agreement, severally waives presentment, demand, protest, and notice of non-payment hereof, binds himself hereon as the principal and not as surety and agrees to remain bound hereon notwithstanding any extension that may be made to any party liable hereon.

You hereby authorize and consent to any contact or inquiry of any person, corporation or business of any kind at the time regarding credit standing and any other financial information. This authorization is in no way limited to or by the trade reference provided on the reverse side of this application. The undersigned indemnify and hold harmless Bassett-Hyland Energy Company from any and all liability connected with such contact or injury.

You agree to send written notice of any disagreement or discrepancy in Bassett-Hyland Energy Company's bill within 30 days of receipt of the same.

YOU HAVE READ AND UNDERSTAND THIS CREDIT APPLICATION AND ACKNOWLEDGE THAT THE ACCURACY OF THE INFORMATION PROVIDED HEREON IS THE BASIS FOR THE EXTENSION OF CREDIT.
Name:*
Acknowledgement*
Accurate Information Provided
Date*
MM slash DD slash YYYY
Name:
Acknowledgement
Accurate Information Provided
Date
MM slash DD slash YYYY
In consideration of credit being extended by Bassett-Hyland Energy Company to the above named applicant for merchandise to be purchased whether applicant be an individual or individuals, a proprietorship, a partnership, a corporation or other entity, the undersigned guarantor(s) each hereby contract and guarantee the faithful payment, when due, for purchases made on this account. The undersigned guarantor(s) each hereby expressly waive all notice of acceptance of this guarantee, notice of extension of credit to applicant, presentment and demand for payment on applicant, protest and notice to undersigned guarantor(s) of dishonor or default by applicant or with respect to any security held by Bassett-Hyland Energy Company, extension of time of payment to applicant, acceptance of partial payment or partial payment compromise, all other notices to which the undersigned guarantor(s) might otherwise be entitled and demand for payment under this guarantee. Any revocation of the guarantee shall be in writing and delivered to Bassett-Hyland Energy Company.
Name:*
Acknowledgement*
Accurate Information Provided
Date*
MM slash DD slash YYYY
Name:
Acknowledgement
Accurate Information Provided
Date
MM slash DD slash YYYY
Completion of this application does not guarantee credit.
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PDF Version of this Application is also Available for Print.
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Coos Bay

Phone: 541-267-2107

Email: scott@bassetthyland.com

425 West Lockhart Avenue
Coos Bay, OR 97420

Roseburg

127 Garden Valley Boulevard
Roseburg, OR 97470

Coos Bay

392 South 4th Street
Coos Bay, OR 97420

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