Last Name:    
First Name:     MI:

Delivery Address:

Nearest Major Crossroad:

Billing Address:

First time buyers must pay C.O.D.

Home Phone:     Work Phone:

Do you rent or own? Rent Own    Color of house?

Renters only: Name and telephone of landlord:

Where did you purchase oil before?

Reason for leaving other oil company:

Type of heating system:    
Size of oil tank: Gals.

What do you prefer? Automatic Delivery Will Call Delivery

Will call service requires a minimum delivery of 100 Gals.

Location of fill pipe...  If facing house, is the fill pipe on the right/left: 

If you would like to have one of our skilled technicians to come to you house please describe the problem:

Please tell us what day and time that you would like a technician to stop by:

Date of birth:

Valid R.I. license number:

S.S.#:

Current Employer:

****************  Service Contracts Are Subject To Inspection.  ******************