APPLICANT NAME:   SS#

SPOUSE NAME:   SS#:

MAILING ADDRESS:

DELIVERY ADDRESS:

PHONE NUMBERS   HOME:     WORK:    CELL:

OWN HOME    RENT    LANDLORD:

EMPLOYER:

EMPLOYER'S ADDRESS:

SPOUSE'S EMPLOYER:

ADDRESS:

PREVIOUS OIL SUPPLIER:

WHAT KIND OF FUEL? OIL  KEROSENE  GASOLINE

DIESEL  BIODIESEL

TANK SIZE: (GAL.)    ESTIMATED USAGE: (GAL.)

TANK LOCATION:   YARD   BASEMENT   UNDERGROUND   CRAWL SPACE

FUEL USED FOR:   HEAT ONLY    HEAT AND HOT WATER

DELIVERY:   AUTOMATIC     WILL CALL

TYPE OF ACCOUNT:   30 DAYS   10 DAYS   BUDGET   C.O.D

LIST TWO (2) CREDIT REFERENCES

NAME:     PHONE:

NAME:     PHONE:

HOW DID YOU HEAR ABOUT US?

NEWSPAPER    PHONE BOOK    TV    RADIO    FRIEND    OTHER

Thank your for your interest

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