Name:
*
Date of Birth
*
Driver's License # and State Issued
*
Mailing Address:
*
City/Town
*
State
*
Zip
*
Home Phone
*
Cell Phone
*
Current Employer
*
Work Number
*
E-mail
*
I'd like to sign up for paperless estatements.
I grant permission to use the above information for credit inquiry purposes.
*
Yes
No (Contact me)
Product and Delivery information
Do you own or rent your home?
Own
Rent
Please provide me with the following fuels:
#2 Heating Oil
BioHeat ® fuel
blend
propane
If you will be a heating fuel customer (oil or propane), how many rooms do you heat?
Would you like to take advantage of our free Automatic Delivery service?
Yes
No
Please call me with more information
My water is heated by
oil
propane
electricity
natural gas
*If by oil or propane, how many bathrooms do you have?
How many gallons of oil or propane do you use annually?
Approximately how many gallons of oil are in your tank now?
My oil tank's fill pipe is located _______ of my house.
in the front
on the driveway side
in the back
on the far side
other
How did you hear about us?