Account Application for Home Heat Customers
Account Application for Home Heat Customers

Please complete the application form below and submit to apply for an account with County Farm Centre.

Applicant Full Legal Name

Is this a joint application?

Full Legal Name (Co-applicant)

Telephone

Mailing Address

Your invoices, payment receipts, and monthly statement will be sent by email to this address.

Delivery Address

My delivery address is the same as my billing address
Own/Rent *

Tank & Appliance Information

Which fuel do you use for home heat? *
Have you purchased a home that County Farm Centre currently supplies with Propane or Furnace Oil?
I have an
*Inspection has been completed by a licensed technician holding certification under TSSA Fuel Oil Regulation 213/01 within 12 months.

Employment

Employment (Co-applicant)

Payment Options

These are the available methods to pay your account:

  • Automatic withdrawal from bank
  • Online banking
  • Cheque
  • Credit Card
  • In-person at one of our 3 locations

Pre-Authorized Payment

Choose the method of pre-authorized payment *
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, 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  • Withdrawn from my bank account on the 20th of the month
  • Charged to my credit card on the 10th 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.

I authorize County Farm Centre to pay my account balance using the above mentioned account or by credit card as per the above payment options. *

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 the Terms of Use and have read the Privacy Policy *
I have read and accept the terms in the Account Agreement *
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