Your Email:

Cardholder Name:

Billing Address:

Credit Card Type: VisaMastercardDiscover

Last 3 Digits of Credit Card:

Expiration Date:

CCV Code:

I authorize Black Bear Fuel Oil, Plumbing, Heating and A/C to charge the sale amount for any home heating oil, On/Off Road Diesel, Kerosene or services rendered for Plumbing, Heating, AC or any general service work to the above listed credit card provided herein or any updated card on my account. I agree that I will pay for this purchase in accordance with issuing bank cardholder agreement.

I agree that Black Bear Fuel Oil, Plumbing, Heating and A/C terms for billing are as follows: All invoices are to be paid within 7 days of sale, if credit approved. I agree to these terms and will pay promptly. If terms are not followed, I authorize Black Bear Fuel Oil, Plumbing, Heating and A/C to charge the credit card on the 8th day from sale or service.

If attorney is needed to recover funds, account holder is responsible for all fees and charges.

Cardholder – Print Name, Sign and Date Below:

Full Name:

Date:

Signature:
click+hold+drag left mouse button to write-in signature or press+hold+drag using touchpad/trackpad to write-in.