* Required fields highlighted 

Personal

Employment

Credit Reference

Fuel Information

Products you will be purchasing:

Gasoline,
Estimated Annual Usage*
LPG/Propane (minimum 24 gallons),
Estimated Annual Usage*
Fuel Oil,
Estimated Annual Usage*
Kerosene,
Estimated Annual Usage*
Blend,
Estimated Annual Usage*
Farm Diesel,
Estimated Annual Usage*

Product Usage check all that apply

Primary Heat
Secondary Heat
Cooking
Drying
Hot Water
Generator
Method of Delivery*
AUTOMATIC
WILL CALL  7-10 days notice required

Tank Information

Fuel Oil, Kero, Diesel, and Gasoline
Horizontal Vertical
Inside Tank: Yes No
Fill Pipe Location:*
Outside Tank: Yes No
Propane
Will we need to schedule an appointment to have Propane tanks set?
Yes No
Notice: a required fuel tank inspection will be done before or at the time of first delivery

Delivery Information

Will you need delivery once your account is established?
Yes No
Current level in Tank:
Full
3/4 Full
1/2 Full
1/4 Full
Empty

Last Supplier

How did you find out about us?*

 Advertisement / Phone Book / Mailing
 Website / Internet Search / Facebook
 Location: saw office, delivery truck, or company vehicle
 Was a customer in the past
 Customer Referral—Name:
 Other:

Why did you choose us?*

 Reputation
 Price
 24 hour Service Dept
 Products Offered
 Special Offer or Coupon
 Social Services / LiHEAP Referral
 Other:

Other products and services

New Heating Equipment
Air Conditioning Equipment
Efficiency Assessment
Annual Equipment Tune-Up
HVAC Equipment Repair
Online Access to your Account
Burner Service Plans
Price Protection Plans
Budget Plans

Would you prefer paperless billing? Yes No

3rd Party Notice (Optional)

If for any reason you are unable to respond to a notice of termination of fuel deliveries because of unpaid balances, you can choose a friend, relative, church group, community organization, or Social Services agency to be informed. Your third party will NOT be responsible in any way for your bill. If you wish to take advantage of this service, fill in the name and address of your 3rd Party.

Contract

NOTICE TO BUYER(S):
A. DO NOT SIGN BEFORE YOU READ AND AGREE TO OUR "TERMS AND BILLING AGREEMENT".
I/we agree to your terms within the agreement at the above link, and the below statement.
B. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AND THE INFORMATION REGARDING YOUR RIGHTS TO DISPUTE BILLING ERRORS. SHOULD YOUR ACCOUNT GO FOR COLLECTIONS OR TO AN ATTORNEY, THE BELOW SIGNED PERSON AGREES TO PAY ANY REASONABLE FEES PERTAINING TO THE COLLECTION OF THE ACCOUNT.
Notice: By submitting this form, I hereby authorize you or any credit reporting agency employed by you to investigate the references herein listed or any of the other information stated above to determine my qualifications for a credit account.