BILLING INFORMATION
* First Name:
Middle Initial:
* Last Name:
* Address:
* City:
* State:
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip:
* Date of Birth:
* Social Security No:
* Home Phone:
Cell Phone:
* Email Address:
* Verify Email:
List Additional owner's name (spouse, partner, etc.) If none, please leave blank.
First Name:
Middle Initial:
Last Name:
Date of Birth:
Social Security No:
DELIVERY ADDRESS
(if same, please leave blank)
Address:
City:
State:
PA
NJ
Zip:
*
Do You Own or Rent?:
Own
Rent
*
How Long at Address:
If Renting, When Does Lease Expire:
*
Is This a Business or Apartment?:
Yes
No
*
If Renting, Does Landlord Pay for Service?:
Yes
No
If yes, please provide:
Landlord Name:
Phone Number:
Address:
EMPLOYER(S)
(please list for each owner listed above)
*
Employer Name:
*
Phone Number:
*
How Long?:
Employer Name:
Phone Number:
How Long?:
If paying by ACH please provide the following, otherwise leave blank.
Bank Name:
Account Number:
Routing Number:
Type of Account:
Checking
Savings
If paying by credit card please provide the following, otherwise leave blank.
Credit Card Type:
Visa
MasterCard
Discover
American Express
Credit Card Number:
Expiration Date:
Month:
1
2
3
4
5
6
7
8
9
10
11
12
Year:
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
Credit Card ID:
How do I find my card identification number?
*
Name of Relative Not Living With You:
*
Relation:
I/WE CERTIFY THAT ALL OF THE INFORMATION ON THIS FORM IS CORRECT. I/WE HAVE READ AND FULLY UNDERSTAND AND AGREE TO YOUR CREDIT POLICY . INTENDING TO BE LEGALLY BOUND, I/WE AGREE TO THESE TERMS IN CONSIDERATION OF CREDIT BEING EXTENDED TO ME/US. I/WE CERTIFY THAT I/WE HAVE THE AUTHORITY TO EXECUTE THIS AGREEMENT ON BEHALF OF ALL OWNERS OF THE PROPERTY DESCRIBED ABOVE. I/WE AUTHORIZE YOU TO INVESTIGATE THE REFERENCES LISTED HERE AND TO REQUEST INFORMATION FROM CREDIT REPORTING AGENCIES.
*
Name:
DELIVERY INFORMATION
Previous Fuel Company (if known):
*
Type of Fuel:
EnviraFuel™
Premium Heating Oil
Propane
Do you own your tank or would you like us to install one for you?:
Own
Install
Tank Size:
100 gal
200 gal
300 gal
500 gal
1000 gal
Other
If other, please specify:
What is your primary use?:
Primary Heat
Hot Water
Pool Heater
Gas Logs
Generator
Cooking
Gas Dryer
Other
If other, please specify:
*
Tank Size:
275 gal
230 gal
2-275 gal
500 gal
Other
*
Automatic Delivery:
Yes
Yes, at specified interval
No
Interval:
(Automatic delivery is convenient and costs you nothing. If interval is not specified, deliveries are made according to degree day methodology.)
*
Where is the Location of Your Fill Pipe or Tank?:
1
2
3
4
5
6
7
8
9
10
11
12
(If a clock were placed over the top of your home or office, which number best describes the location of the fill pipe or tank, with 12 being the rear and 6 being the front?)
First Delivery Date:
IMPORTANT: If this is the first time we are delivering to this address, someone must be home for our driver to inspect the tank, (1st delivery only). You can waive this requirement by acknowledging that your tank is installed and operating properly and there are no signs of deterioration or leaks. All connecting piping is iron pipe. There is no PVC piping.
Name:
Date:
Special Delivery Instructions:
SERVICE INFORMATION
*
Would You Like a Maintenance Agreement?:
Yes
Not at this time
Please send more info
*
Is Your Heating System a Furnace or Boiler?:
Furnace (blows warm air)
Boiler (hot water heater)
*
Do you know the approximate age of your heating system?:
*
Do you want to setup an appointment to have your heating system cleaned and tuned up?:
Yes
No
If yes, what would be a good time for you?:
*
Do we have your permission to conduct a credit check?:
Yes
No
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