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Name :
Drivers License (No & State Where Issued) :
Delivery Address :
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SS# :
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Zip :
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Email :
Do you own or rent your home?
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Permission is granted to use the above information for credit inquiry purposes.
Product And Delivery Information
Please Provide me with the following fuel(s):
#2 heating oil
BioHeat ® fuel
K1
blend
propane
Would you like to take advantage of our free Automatic Delivery service?
Yes
No
Please call me with more information
If you will be a heating fuel customer (oil or propane), how many rooms do you heat?
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
Do you use oil or propane for water heating?
Yes
No
If yes, how many bathrooms do you have?
01
02
03
04
05
06
07
08
09
10
Do you know how many gallons of oil or propane do you use annually?
don't know
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
Our water is heated by :
oil
propane
electricity
natural gas
How did you hear about us?
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