Residential Form – Bermuda Gas

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Last Name(Required)

First Name(Required)

Middle Initial(Required)

Maiden Name(Required)

(if applicable)

Date of Birth

Street Address

Directions to House(Required)

Colour of House(Required)

Colour of Blinds / Woodwork(Required)

Mailing Address(Required)

(if different from above)

E-mail Address(Required)

(for e-billing)

Tel(Required)

Fax

Cell

Employer’s Name

Employer’s Tel(Required)

Number of years at present employer

Address (Own/rent)

Own

Rent

If Rent - How many years at current address

Landlord’s Name

Landlord’s Address

Landlord’s Tel(Required)

Landlord’s Email

Photo Identification:

Driver’s Licence No

Passport No

Upload Photo ID(Required)

Max. file size: 50 MB.

Credit Card:

Personal Credit Card Information will not be held on file

Card

MasterCard

Visa

Name on Card

Card Number

Expiration date

CVS

Credit Card Billing Address

A separate Auto Payment Agreement may be requested upon receipt of your authorization.

TERMS:
I understand that gas cylinders and tanks supplied by Bermuda Gas & Utility Company Ltd., hereinafter referred to as BGU, to my premises remain the property of BGU and that BGU shall have an exclusive right to refill and maintain the said cylinders and tanks. BGU shall attend at my premises and recover each cylinder to be refilled or repaired and shall replace each cylinder so recovered with a replacement cylinder properly filled with LPG or alternatively BGU will attend my premises to refill tanks from a bulk delivery vehicle. I recognise that no third party supplier shall refill or repair the cylinders or tanks provided by BGU, whether in situ or off premises. I recognise that any breach of this agreement entitles BGU to an immediate right to recover the cylinders or tanks in my possession and terminate this agreement, without notice to me and without any credit for any unused LPG, and will negate any consumer safety protection. I agree to the policies, terms and conditions of BGU. These policies, terms and conditions are subject to change upon notification from BGU. I give permission to BGU to obtain information from any source to verify any statements made in this application. I understand that this account will be activated upon confirmation of receipt by BGU of the required pre-payment. I agree to advise BGU of any change to the information provided herein or in the event that I plan to leave the Island. I agree that all late payment fees, agency charges, legal costs and other expenses incurred by BGU in attempting to recover overdue amounts will be charged to my account. Late fees will be incurred if payment is not received within 30 days of statement date. Late fees will be the greater of either $5.00 or 3% of the overdue balance. This provision shall survive termination of this agreement, howsoever caused, and whether at the instance of the customer/you or BGU.

Signature

Date

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