SSN or Account Number:*
The undersigned, gives permission to Kemgas to charge his or her credit card listed below the total amount due on each billing statement.THIS CHARGE WILL RUN ON THE FOLLOWING BUSINESS DAY AFTER THE DELIVERY DAY.
My account will be charged, for current purchases on each statement, as long as this contract is valid. I understand that if my card comes back as “DECLINED” I will be charged a $25.00 decline fee. This contract will be valid until I, the undersigned, give my request, in writing, to stop regular payments.
Select Payment Method:*
-select-Credit CardBank Account
Last 3 digit code on back of card:*
Name on Card:*
Card Mailing Address:*
By typing your full name & today's date you are signing this form and agreeing to terms with Kemgas
Bank Routing #:*
Bank Account #:*
Name on Account:*
By typing your full name and today's date you are signing this form< & agreeing to terms with Kemgas
**Signing up for Auto-Pay automatically qualifies your account for $.10 off per gallon when eligible**(If your payment declines, your account may be removed from the discount if not resolved)