Miles LP Gas - Credit Consent

Credit Consent

If you would like to apply for charge status, fill out this form.

Customer Name*

Please choose a Customer Name.

Please type a First Name.

Date of Birth*

Please choose a Date of Birth.

Spouse Full Name

Spouse Date of Birth

Please choose a Date of Birth.

Applicant SS#*

Please choose a Applicant SS#.

Spouse SS#

Mailing Address*

Please choose a Mailing Address.

Phone Number*

Please choose a Phone Number.

Phone Number*

Please choose a Phone Number.

Email Address

In compliance with the credit reporting act, this is to inform that you are authorizing this organization and/or it’s suppliers to obtain an investigative consumer credit report&/or business credit report. You have the right to dispute the the information on this report and request additional disclosures provided under section 606 & 1681d(B). You may do this by contacting the provider of this information. Please call onecreditsource.com at 1(800) 905-9678 and you will be directed to the proper credit reporting agency or assisted in your inquiry. This organizatino is not allowed to give you a copy of your credit report. You also release from liability any persons involved in the credit investigation.

I certify, to best of my knowledge, that all statements above are true and complete.I authorize Miles LP Gas and its suppliers to obtain any and all information related to credit information and credit worthiness related to obtaining credit from Miles LP Gas.