Thank you for applying for a Buell Fuels Local Gas credit card. If approved your new card allows you to enjoy the convenience of being billed every Tuesday and you’ll save 12¢ per gallon!
I authorize Local Gas to verify information provided on this form regarding credit, personal and employment history.
I (we), herinafter called CUSTOMER, hereby authorize LOCAL GAS, LLC (LOCAL GAS) to initiate electronic entries to CUSTOMER's bank account at the Depository Institution indicated below and further directs said Depository Institution to accept and debit/credit the amount of such entries to CUSTOMER's account:
This authority shall remain in effect until terminated by written notice by either CUSTOMER or LOCAL GAS. Effective Date of termination will be fifteen (15) days after receipt of written notice.
Notice of termination shall in no way affect debit/credit entries initiated by LOCAL GAS prior to actual receipt of notice.
CUSTOMER agrees to be responsible for Bank's processing charge for all items. LOCAL GAS will be responsible for all costs associated with delivery of debits/credits to the CUSTOMERS bank.
All credit and other terms and requirements between CUSTOMER and BUELL remain in effect. I do certify that I have the full capacity and authority to authorize and direct.
As a customer of Local Gas, we need to make you aware of the following guidelines so we may best serve your 11eeds. Failure to meet terms listed below may result in Local Gas refusal to serve you.
By signing below, I accept the above terms and conditions and agree to pay for all purchases made by the Buell Fuels Local Gas card assigned to me. If the card is lost or stolen, I assume all responsibility until Local Gas is legally notified by me in written form, in person, or by certified mail.
I am the financially responsible party for this account.
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