Residential New Customer Agreement You are here: Home / Become A Customer / Residential New Customer Agreement Residential New Customer Agreement "*" indicates required fields PersonalNew Customer Name* First Middle Initial Last New Customer Date of Birth* Month Day Year Second New Customer Name (Optional) First Middle Initial Last Second New Customer Date of Birth (Optional) Month Day Year Home Phone*Work PhoneMobileEmail* Mailing Address* PO Box or No. & Street City/Town State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip 911 Physical Address* No. & Street City/Town State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Landlord Name or Previous Owner Landlord PhoneCurrent Housing Status* Own Rent Years at this Address*Have you been at your current address for fewer than 10 years?* Yes No Previous Address*If you have moved in the last 10 years, please enter previous address. No. & Street City/Town State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code EmploymentEmployer* PhonePosition Years ThereSecond Employer PhonePosition Years ThereCredit ReferencePlease provide a credit reference (bank name, utility, credit card, etc)* Fuel InformationProducts you will be purchasing:Gasoline Yes No Estimated Annual Gasoline Usage* LPG/Propane Yes No Estimated Annual LPG/Propane Usage* Fuel Oil Yes No Estimated Annual Fuel Oil Usage* Kerosene Yes No Estimated Annual Kerosene Usage* Farm Diesel Yes No Estimated Annual Farm Diesel Usage* Clear Diesel Yes No Estimated Annual Clear Diesel Usage* Product Usage check all that applyProduct Usage check all that apply Primary Heat SecondaryHeat Cooking Drying Hot Water Generator Method of Delivery* AUTOMATIC WILL CALL 7-10 days notice required Tank InformationFuel Oil, Kerosene, Diesel, and GasolineNotice: a required fuel tank inspection must be done before or at the time of the first delivery.Tank Size / Capacity Tank Shape Horizontal Vertical Inside Tank Yes No Fill Pipe Location* Outside Tank Yes No Outside Tank Location* PropaneL/P Tank PercentageL/P Tank Size / Capacity Will we need to schedule an appointment to have Propane tanks set? Yes No Delivery InformationAttention: if a secondary heating source is in use at this location, such as a pellet or wood stove, you are responsible for run-outs — even if you have signed up for automatic delivery.Will you need delivery once your account is established? Yes No Date of Last Delivery Month Day Year Number of Gallons DeliveredCurrent Level in Tank Full 3/4 Full 1/2 Full 1/4 Full Empty Directions to Delivery Location Color of Building* Landmarks Last SupplierName & Address Reason for Changing How did you find out about us?*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 Other Why did you choose us?*Why did you choose us?* Reputation Price 24 Hour Service Products Offered Social Services / LiHEAP Referral Special Offer, Coupon or Promo (enter code below) Other Enter Promo Code Other Products & ServicesOther Products & 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.Name of Third Party PhoneAddress Contract*Contract*NOTICE TO BUYER(S): A. DO NOT SIGN BEFORE YOU READ AND AGREE TO OUR TERMS AND BILLING AGREEMENT 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, YOU, THE ACCOUNT HOLDER, AGREE 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. I/we agree to your Terms & Billing Agreement, and the above statement.* Paper Application Residential Customers, if you’d prefer to print a form, fill it out and mail or submit in person:New Customer Application PDF Commercial Customers apply here Related Pages FuelsServicesFuel Delivery InfoContact Us
