if you prefer to print and fax this form, click here

Please complete the following items being sure to provide your phone numbers. Although this is secure, if you do not wish to complete your social security number you may call it in to our office. Only completed accounts will be considered. Please click HERE for your copy of our Billing Information & Retail Credit Agreement


Name:  

Street Address: 

City:  State     Zip 

Phone:  e-mail address: 

What are we delivering:  oil   

Is this a yearly maintenance Service call?  Yes    No

Which day of the coming week would you like your delivery? or service maintenance?

Monday    Tuesday      Wednesday    Thursday   Friday

How much do you want delivered?

150 gallons 200 gallons Fill

How much is in your tank now?

How will you pay:

Monthly Account Billing

COD

Check

Cash

Credit Card

Please provide you email for our confirmation: 

PLEASE ALLOW 24hrs FOR CONFIRMATION.  IF THIS IS AN EMERGENCY after 4:30 PM PLEASE CALL 732-409-3871

 

 


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