Account Application Consolidated Account Application - updated Oct 2025 Please complete the application form below and submit to apply for a residential or commercial account with County Farm Centre. Residential or Commercial Account What type of account are you applying for? * Residential Commercial Apply for a Residential account if you are seeking home heating. Apply for a Commercial account if you are operating as a business or operating under a registered business name. Products What products are you interested in? Propane Heating Oil Agronomy Nutrition/Feed Retail Store Petroleum Agronomy Retail Store Nutrition/Feed Applicant - Full Legal Name First * Middle Last * Applicant Birth Date * Is this a joint application? Yes Co-applicant - Full Legal Name First * Middle Last * Co-applicant Birth Date * Billing Address 911 #/ Road Name * City/Town * Province * AlbertaBritish ColumbiaManitobaNova ScotiaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Use format R7R 7R7 (letter, number, letter, ...) Delivery Address Own/Rent * Own Rent My delivery address is the same as my billing address 911 #/ Road Name * City/Town * Province * AlbertaBritish ColumbiaManitobaNova ScotiaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Use format R7R 7R7 (letter, number, letter, ...) Landlord Name * Landlord Phone How long have you lived at this address? 0-3 years More than 3 years Previous Address 911 #/Road Name * City/Town * Province * AlbertaBritish ColumbiaManitobaNova ScotiaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code * Use format R7R 7R7 (letter, number, letter, ...) Business Identification Identity * Proprietorship Corporation Limited Co-operative Full Legal Name of Farm / Business * Date Business Established * Farm/Business Number Business Address - Physical Address * City/Town * Province * AlbertaBritish ColumbiaManitobaNova ScotiaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code * Is delivery address of fuel different than this Business Address? Yes My business mailing address is the same as the physical address Fuel Delivery Address Address * City/Town * Province * Ontario Postal Code * Business Address - Mailing Address * City/Town * Postal Code * Additional Contact Info Email Address * Your invoices, payment receipts, and monthly statement will be sent by email to this address. Phone * Secondary Work Land & Equipment Land & Buildings * Owned Rented Legally Registered to * Name of Landlord * Equipment * Owned Leased If leased, from whom * Total Acres Acres Owned Acres Rented Grower Pesticide License # Expiry Officers/Partners Full Legal Name * Title * Date of Birth * Phone * plus1 Add Another minus1 Remove * You must have at least one Officer. Propane Tank & Appliance Information Have you purchased a home that County Farm Centre currently supplies with Propane? Yes No Oil Tank & Appliance Information Have you purchased a home that County Farm Centre currently supplies Furnace Oil? Yes No I have an inspection for my oil tank* inspection for my heating appliance* *Inspection has been completed by a licensed technician holding certification under TSSA Fuel Oil Regulation 213/01 within 12 months. Please upload copies of your inspection documentation Drop a file here or click to upload Choose File Maximum file size: 134.22MB Employment Current Employer * * If you are retired, simply enter “retired” in all three boxes above Position * How Long? * Employment (Co-applicant) Current Employer * * If you are retired, simply enter “retired” in all three boxes above Position * How Long? * Financial Info Bank * Branch * Branch Phone # * If requested, would you be able to provide recent financial statements? Yes Financing Do you require financing? Yes No Our financing expert will contact you with details on our Agri-Finance Program References Trade Reference/Supplier * Phone * Fax plus1 Add minus1 Remove * You must have at least one Reference. Requested Credit: Propane Amount of Credit Requested * Requested Credit: Heating Oil Amount of Credit Requested * Requested Credit: Dieselex Gold Amount of Credit Requested * Requested Credit: Agronomy Amount of Credit Requested * Requested Credit: Retail Amount of Credit Requested * Payment Options These are the available methods to pay your commercial account: Automatic withdrawal from bank Online banking Electronic Funds Transfer (EFT) Email Money Transfer (EMT) Cheque In-person at one of our locations Equal billing available for residential accounts In-person at one of our locations Do you wish to sign up for pre-authorized payment (automatic withdrawal from bank account or credit card)? No Yes Do you wish to sign up for equal payments plan? * Yes No We will contact you to set up a payment plan. Pre-Authorized Payment Choose the method of pre-authorized payment Automatic withdrawal from my bank account on the 20th of every month Automatic charge on my credit card (Visa/MC Only) on the 15th and 30th of every month Name on Account * Transit Number * Institution Number * Account Number * Name Phone For your security, please provide a phone number you can be reached at, and we will contact you to obtain your credit card information. I authorize County Farm Centre to pay my account balance using the above mentioned account as per the above payment options. I authorize County Farm Centre, and the financial institution designated (or any other financial institution I may authorize at any time) to begin deductions as per my/our instructions for monthly regular reoccurring payments of all charges arising under my/our County Farm Centre account(s). I authorize the balance owing on my/our County Farm Centre account statement to be: Withdrawn from my bank account on the 20th of the month This authority is to remain in effect until County Farm Centre has received written notification from me/us of its change or termination. This notification must be below. I may obtain a sample cancellation form, or more information on my/our right to cancel a Pre-Authorized Payment (PAP) Agreement at my/our financial institution or by visiting www.payments.ca. County Farm Centre may not assign this authorization, whether directly, by operation of law, change of control or otherwise, without providing at least ten (10) days prior written notice to me/us. I have certain recourse rights if any payment does not comply with this agreement. For example, I have the right to receive reimbursement for any PAP that is not authorized, or is not consistent with this PAP Agreement. To obtain a form for a Reimbursement Claim, or for more information on my/our recourse rights, I may contact my/our financial institution or visit www.payments.ca. THE UNDERSIGNED ALSO UNDERSTANDS THAT ALL PURCHASES ARE DUE AND PAYABLE IN FULL NO LATER THAN THE 20TH OF THE MONTH FOLLOWING PURCHASE. THE UNDERSIGNED CERTIFIES THE ABOVE INFORMATION TO BE TRUE AND AFFIRMS THAT ANY CREDIT GIVEN TO ME IS EXTENDED ON THE BASIS OF SUCH INFORMATION. The undersigned consents to the obtaining of credit and / or personal information as may be required at any time in connection with the credit hereby applied for or any renewal or extension thereof and to the disclosure of any credit information concerning the undersigned to any credit reporting agency or to any person with whom the undersigned has or proposes to have financial relations. THE UNDERSIGNED FURTHER ACKNOWLEDGES THAT I HAVE BEEN INFORMED OF YOUR PREVAILING TERMS FOR REPAYMENT AND AGREE TO PAY AN INTEREST CHARGE OF 2% PER MONTH (24% PER ANNUM) ON ANY OVERDUE BALANCE UNTIL PAID. Authorization I agree to a Credit Check Yes If you decline a credit check you will be required to prepay for products and services. Please confirm you do not require credit * Yes If you decline a credit check you will be required to prepay for products and services. I agree to the Terms of Use and have read the Privacy Policy * Yes I have read and accept the terms in the Account Agreement * Yes Comments Officer/Partner Signature * signature keyboard Clear Applicant Signature * signature keyboard Clear Co-applicant Signature * signature keyboard Clear Additional Signature Required 2nd Officer/Partner Signature * signature keyboard Clear Name * Title * Captcha Submit If you are human, leave this field blank.
