CUSTOMER CREDIT APPLICATION & WATER ACCOUNT SETUP FORMPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Which Hicksgas Services are you applying for: *Propane Sales & ServiceWater ConditioningBoth ServicesPlease select the Hicksgas location nearest you: *Belvidere, ILBloomington, ILBraidwood, ILCanton, ILDecatur, ILDekalb, ILDemotte, INFairbury, ILKankakee, ILKnox, INLafayette, INLake Villa, ILLincoln, ILMarseilles, ILMorton, ILOakwood, ILPontiac, ILRensselaer, INRoberts, ILSpringfield, ILToluca, ILUrbana, ILVandalia, ILWatseka, ILWoodstock, ILHow did you hear about us? *How did you hear about us?Internet SearchCustomer ReferralTrucks/TanksAdvertisementDirect MailSocial MediaPrimary Applicant Name *FirstLastPrimary Applicant Street Address, City, State, Zip *How long at this address? *Primary Applicant Email *Primary Applicant Phone *Primary Applicant Date of Birth *Primary Applicant Employer *Primary Applicant Position/Job Title *Primary Applicant Employer Street Address, City, State, Zip *Primary Applicant Employer Phone *Primary Applicant Length of Employment *FINANCIAL REFERENCES - Primary Applicant Bank - Name *Bank - Phone *Bank - City/State *Landlord or Mortgage Company - Name *Landlord or Mortgage Company - Phone *Landlord or Mortgage Company - City/State *Utility Company - Name *Utility Company - Phone *Utility Company - City/State *IMPORTANT NOTICE TO CUSTOMER *By signing below, you agree to the following1. The information supplied is accurate as of the date shown; 2. An investigation of all statements or other credit data herein and release of such information to DCC Propane, LLC or any of its subsidiaries, from any and all sources is authorized; 3. A release is granted to all parties from all liability for any damage that may result from furnishing information to you; 4. To recognize that your individual credit history may be a factor in the evaluation of this credit application; and, 5. Consent to and authorize the use of any external credit reporting information utilized by DCC Propane, LLC or any of its subsidiaries, from time to time as may be needed.Date / Time *DateTimeCo-Applicant Information (if applicable) - ALL FIELDS ARE REQUIRED FOR A CO-APPLICANTCo-Applicant NameFirstLastCo-Applicant Employer Co-Applicant Position/Job TitleCo-Applicant Employer Street Address, City, State, ZipCo-Applicant Employer PhoneCo-Applicant Length of EmploymentIMPORTANT NOTICE TO CUSTOMER - Co-ApplicantREQUIRED if there is a Co-Applicant. By signing below, you agree to the following1. The information supplied is accurate as of the date shown; 2. An investigation of all statements or other credit data herein and release of such information to DCC Propane, LLC or any of its subsidiaries, from any and all sources is authorized; 3. A release is granted to all parties from all liability for any damage that may result from furnishing information to you; 4. To recognize that your individual credit history may be a factor in the evaluation of this credit application; and, 5. Consent to and authorize the use of any external credit reporting information utilized by DCC Propane, LLC or any of its subsidiaries, from time to time as may be needed.Co-Applicant Signature Date / Time DateTimeLayoutSubmit
