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Today's Date:
New Propane Customer Information
Name:
Location Address:
City:
Zip:
Mailing Address:
Home Phone:
Work Phone:
Sq. Ft. of Home:
Heat: Water: Cooking:
Nearest Relative
Phone:
Address:
Tank Information
Tank Size:
Do You Own the Tank? Yes: No:
Tank Size Other:
If another propane service owns the tank, WE CANNOT FILL IT. For information on leasing or purchasing a tank from us, call 1-877-558-5770.
If you are a renter and your landlord owns the tank, please fill out the following information on your landlord.
Landlord
Line Information
Is the Line Installed? Yes: No:
Has the Line Been Inspected? Yes: No:
Even if a line has not been installed, still proceed to send us this form. This will allow us to file your information. Call us when you have the line installed to set up a date for tank delivery.
Site Information
Will you need to purchase or lease a tank from us? Yes: No:
Date Tank Needed:
Pad: Concrete Blocks:
Are the pad or blocks currently in place? Yes: No: We do NOT install pads for tanks. We will install tanks on pads already in place.
Directions to Site:
Consumer Information
Old Propane Supplier:
Why You Changed:
Comments:
