Application for Automatic Oil Delivery

Your Name

Your Email

Your Phone Number

Present Address

Driver's License Number

Rent / Own / Lease

Rent

Own

Lease

Landlord

Landlord Phone Number

Employed By

Previous Supplier

Automatic Delivery

Yes

Tank Size

Tank Level

Will Call

Fill Pipe Location

Number of Rooms

Type of Burner

Heat

Heat & Hot Water

Free Text

PLEASE HAVE YOUR SPOUSE COMPLETE THE FOLLOWING

Your Name

Your Work Phone Number

Driver's License Number

Employed By

NOTICE TO BUYER(S)

You are entitled to a copy of this agreement and the information regarding your right to dispute billing errors
You may at any time pay off the full unpaid balance
Any changes to original account application set-up must be received by fax or mail

Field label

NOTE: Service contract goes into effect once heating system has been evaluated during annual cleaning. Pre-existing conditions are not covered.

Buyer(s) hereby acknowledges receipt of a true copy of this credit agreement and billing errors information.

Free Text

NOTICE: I hereby authorize you or any credit reporting agency employed by you to investigate the references listed and any of the other information states about to determine my qualifications for a credit amount.

I certify that the information on this application is true and correct.

Yes

Date