If approved, your new card allows you the convenience of being billed every Tuesday at a discounted rate per gallon for fuel at our pumps.

This information helps us evaluate your application. All information provided will be kept confidential and used solely for account approval and administration purposes.

I hereby authorize Local Gas, LLC. (Local Gas) to initiate electronic entries to my bank account at the Depository Institution indicated below and further direct said Depository Institution to accept and debit/credit the amount of such entries to my account:

This authority shall remain in effect until terminated by written notice by either CUSTOMER or LOCAL GAS. Effective Date of termination will be fifteen (15) days after receipt of written notice. Notice of termination shall in no way affect debit/credit entries initiated by LOCAL GAS prior to actual receipt of notice. CUSTOMER agrees to be responsible for Bank's processing charge for all items. LOCAL GAS will be responsible for all costs associated with delivery of debits/credits to the CUSTOMER'S bank.
All credit and other terms and requirements between CUSTOMER and BUELL remain in effect. I do certify that I have the full capacity and authority to authorize and direct.