Credit Card Authorization Form

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21 AUSTIN DRIVE MARLBOROUGH, CT 06447 PHONE: 860-365-5218 FAX: 860-365-5219

TO WHOM IT MAY CONCERN:

THIS IS TO AUTHORIZE CONNECTICUT PROPANE & PETROLEUM TO CHARGE MY CREDIT CARD FOR ANY MONTHLY BALANCES THAT I MAY INCUR AT THE ADDRESS MENTIONED BELOW:

NAME: _____________________________________________________________________ ADDRESS: __________________________________________________________________ CITY: ________________________________________STATE:___________ ZIP:________ PHONE NUMBER: ________________________ CELL PHONE: _____________________ VISA/MC/ NUMBER: ___________________________________________________ EXPIRATION DATE: _____________________ EMAIL: (For Receipt of EachTransaction): _________________________________________

SIGNATURE

DATE

PLEASE NOTE: Future gas deliveries and rental charges will be charged to this credit card upon delivery.