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Westmore Fuel Co. Inc

86 North Water Street

Greenwich, C.T 06902

203-531-5656 or 914-939-2473

www.WestmoreFuel.com

CREDIT CARD PAYMENT AUTHORIZATION FORM

Please fill in the information below for either credit card or electronic funds transfer and fax back to 203-531-5783.Or you mail to the above address.

Name: __________________________________________________________________

Name on Credit Card: _____________________________________________________

Billing Address: _________________________________________________________

Credit Card Number: ______________________________________________________

Type of Credit Card (circle):       MasterCard     or     Visa      

Expiration Date: ______________________________

I authorize Westmore Fuel Co. Inc. to automatically apply charges for my oil heating bills/ service bills at their regularly scheduled billing intervals to the charge card account indicated above.

Signature: ________________________________________       Date: _____________

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM

As a duly authorized check signer on the financial institution account, void check attached. I authorize Westmore Fuel Co. Inc. to perform scheduled or periodic electronic funds transfer debits and or/credits from my account for payments due or when applicable, apply electronic funds transfer credits to the same. This applies to check by phone payments as well as any other electronic payment.

Furthermore, if any such electronic debit(s) should be returned by my financial institution as Non-Sufficient Funds (NSF), I authorize, Westmore Fuel Co. Inc., to collect a returned item fee of $40.00 per item by electronic debit from my account.

For accounting purposes, all electric debits will be reflected in the monthly bank statement that corresponds with the financial institution account by voided check attached.

I understand and authorize all of the above as evidence by signature below.

AUTHORIZING SIGNATURE: _________________________DATE: ____________

NAME & ADDRESS: ___________________________________________________