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Residential Credit Application

To apply for residential credit with Deiter Bros., either complete this online form and click the Submit button or download this Residential Credit Application and mail or fax it back to us.

The red * indicates required fields.


BILLING INFORMATION
* First Name:
Middle Initial:
* Last Name:
* Address:
* City:
* State:
* Zip:
Date of Birth:
* Social Security No:
* Home Phone:
Cell Phone:
* Email Address:
* Verify Email:

List Additional owner's name (spouse, partner, etc.) If none, please leave blank.
First Name:
Middle Initial:
Last Name:
Date of Birth:
Social Security No:

DELIVERY ADDRESS
(if same, please leave blank)
Address:
City:
State:
Zip:
* Do You Own or Rent?:
* How Long at Address:
If Renting, When Does Lease Expire:
* Is This Business or Apartment?:
* If Renting, Does Landlord Pay for Service?:
If yes, please provide:
Landlord Name:
Phone Number:
Address:

EMPLOYER(S)
(please list for each owner listed above)
* Employer Name:
* Phone Number:
* How Long?:
Employer Name:
Phone Number:
How Long?:
If paying by ACH please provide the following, otherwise leave blank.
Bank Name:
Account Number:
Type of Account:
Name of Relative Not Living With You:
Relation:
I/WE CERTIFY THAT ALL OF THE INFORMATION ON THIS FORM IS CORRECT. I/WE HAVE READ AND FULLY UNDERSTAND AND AGREE TO YOUR CREDIT TERMS. INTENDING TO BE LEGALLY BOUND, I/WE AGREE TO THESE TERMS IN CONSIDERATION OF CREDIT BEING EXTENDED TO ME/US. I/WE CERTIFY THAT I/WE HAVE THE AUTHORITY TO EXECUTE THIS AGREEMENT ON BEHALF OF ALL OWNERS OF THE PROPERTY DESCRIBED ABOVE. I/WE AUTHORIZE YOU TO INVESTIGATE THE REFERENCES LISTED HERE AND TO REQUEST INFORMATION FROM CREDIT REPORTING AGENCIES.
* Name:

DELIVERY INFORMATION
Previous Fuel Company (if known):
* Type of Fuel:
* Tank Size:
* Automatic Delivery:
* Where is the Location of Your Fill Pipe?:	(If a clock were placed over the top of your home or office, which number best describes the location of the fill pipe, with 12 being the rear and 6 being the front?)
First Delivery Date:
IMPORTANT: If this is the first time we are delivering to this address, someone must be home for our driver to inspect the tank, (1st delivery only)
Special Delivery Instructions:


SERVICE INFORMATION
* Would You Like a Maintenance Agreement?:
* Is Your Heating System a Furnace or Boiler?:
* Do you know the approximate age of your heating system?:
* Do you want to setup an appointment to have your heating system cleaned and tuned up?:
If yes, what would be a good time for you?:
* Do we have your permission to conduct a credit check?:




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Deiter Bros. provides fuel oil, heating oil, hvac, heating, air conditioning, radiant heat, heat pump, furnace, onsite and fleet fueling, and other indoor comfort services in the following locations: Alburtis, Allen Township, Allentown, Alpha, Bangor, Bath, Bethlehem, Bloomsbury, Bushkill Township, Catasauqua, Chestnut Hill Township, College Hill, Coopersburg, Coplay, East Allen Township, Easton, Emmaus, Forks Township, Fountain Hill, Freemansburg, Hanover Township, Harmony Township, Hellertown, Lehigh County, Lehigh Township, Lehigh Valley, Lower Macungie Township, Lower Mt. Bethel Township, Lower Nazareth, Lower Nazareth Township, Lower Saucon, Lower Saucon Township, Macungie, Moore Township, Nazareth, North Catasauqua, North Whitehall, Northampton County, Palmer, Palmer Township, Pen Argyl, Phillipsburg, Plainfield Township, Roseto, Salisbury, Saucon Valley, Slatington, South Whitehall, Stewartsville, Stockertown, Tatamy, Trexlertown, Upper Macungie, Upper Nazareth, Upper Nazareth Township, Upper Saucon, Walnutport, Warren County, Washington, Washington Township, West Easton, Whitehall, Willams Township, Wilson Borough, Wilson, Wind Gap and surrounding areas!
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