Application for Automatic Oil Delivery

Your Name*

Your Email*

Your Phone Number *

Present Address*

Driver's License Number*

Rent / Own / Lease*
RentOwnLease

Landlord*

Landlord Phone Number*

Employed By*

Previous Supplier*

Automatic Delivery*
YesNo

Tank Size*

Tank Level*

Will Call*

Fill Pipe Location*

Number of Rooms*

Type of Burner*

Heat*

Heat & Hot Water*

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

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.

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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*