Pgagnon - Contact Us - Become Our Customer - Provides heating oil, propane and heating services

Become Our Customer

*= Required Field

* NAME :

* DRIVERS LICENSE (NO. & STATE WHERE ISSUED) :

DELIVERY ADDRESS :

DATE OF BIRTH :

* TOWN :

* HOME PHONE :

* MAILING ADDRESS :

* STATE :

* ZIP :

* CURRENT EMPLOYER :

* WORK PHONE :

DO YOU OWN OR RENT YOUR HOME?

Own

Rent

*	PERMISSION IS GRANTED TO USE THE ABOVE INFORMATION FOR CREDIT INQUIRY PURPOSES.

PRODUCT AND DELIVERY INFORMATION

PLEASE PROVIDE ME WITH THE FOLLOWING FUEL(S):

WOULD YOU LIKE TO TAKE ADVANTAGE OF OUR FREE AUTOMATIC DELIVERY SERVICE?


	YES
	NO
	PLEASE CALL ME WITH MORE INFOMATION

IF YOU WILL BE A HEATING FUEL CUSTOMER (OIL OR PROPANE), HOW MANY ROOMS DO YOU HEAT?

DO YOU USE OIL OR PROPANE FOR WATER HEATING?

Yes

IF YES, HOW MANY BATHROOMS DO YOU HAVE?

DO YOU KNOW HOW MANY GALLONS OF OIL OR PROPANE DO YOU USE ANNUALLY?

DON'T KNOW

APPROXIMATELY HOW MANY GALLONS OF OIL ARE IN YOUR TANK NOW?

MY OIL TANK'S FILL PIPE IS LOCATED _______ OF MY HOUSE.

OUR WATER IS HEATED BY:

HOW DID YOU HEAR ABOUT US?