New Account Form

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New Account Form
Seacoast Energy Solutions
PO Box 448, Newcastle ME 04553
PH: 207-563-7188 Fx: 207-563-7295
Last Name, first name, middle initial:
Social Security #:
2
Applicant name:
nd
Social Security #:
Billing Address:
City, State, Zip:
Physical Address:
City, State, Zip:
Email address:
Home phone:
Cell phone:
Employer name:
Work Phone:
Own _____ Rent _____
Landlord address:
Landlord name and phone:
What form of payment would you prefer to use? Circle one: CREDIT CARD / DEBIT CARD / CHECK / CREDIT TERMS
Expiration Date:
3 digit security code:
Credit/Debit Card Type and #:
MC__ VISA__
Complete Name and address to which credit card bill is received:
COD ______ All deliveries and services paid with check or cash
Credit ______ Submit payment within 30 days once credit
at time of service.
approved.
What brought you to us today? Referral _____ Newspaper Ad _____ Press Release ______ Website _____ Radio _____ Previous
Owner _____ Other _____________
Terms and Conditions: 1) Seacoast Energy Solutions (SES) extends credit to qualified applicants on 30 day terms. Balance beyond terms will be
assessed a 1.5% finance charge. Accounts with a past due balance are subject to cancellation of price protection programs, automatic delivery and
any type of any service plans. SES reserves the right to withdraw credit at any time including at delivery. By signing this application, you are
agreeing to pay all court costs and attorney’s fees incurred by SES should SES need to pursue collection of monies owed by you. 2) SES is
authorized to check Customer’s credit. 3) $25 fee will be charged for any unpaid returned check. 4) Payment terms; all other charges or outstanding
balances must be paid in full before customer can participate in any price protection or service agreement programs. Non-payment of any program
fee voids this agreement. 5) Customer agrees to pay all labor, parts and charges associated with propane tank installs and pick-ups or oil and
propane code related updates according to Maine State code requirements.
Credit Card Processing:
By providing credit card information above and signing this form customer agrees to the following; all products and services including parts, labor
and charges will be paid by this method. The account information provided by this form including credit card # will be used for this purpose. Should
a customer elect to revoke or dispute a transaction, a written request shall be made to: SES, PO Box 448, Newcastle ME 04553 stating the nature
of the dispute. SES will provide resolution to such dispute within 30 days of receiving notice. Agreeing to these terms, customer hereby authorizes
SES to debit the account provided for goods, services and charges received on account.
Other Credit Card Option:
SES offers its customers an online Electronic Bill Pay Service that allows its customers to view account information and electronically pay bills. This
option must be set up by the customer from SES’s website
Applicant Signature: ____________________________________________
Date:______________________
2nd Applicant Signature: _________________________________________
Date:______________________

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