Applicant Name
SS Number
Phone*
E-mail*
Delivery Address *
City *
State *
Zip *
Check if Address is The Same For Billing
Billing Address
City
State
Zip
Special Instructions
Can Driver park in the driveway if fill pipe is less than 125 from the street?
YesNo
How did you hear about us?
How is your fill pipe marked?
Fill Location: (Click approx. location eg. BL = back left)
blbcbrrrrcrffrfcfllflclr
Landlord's Name
Phone
Does Landlord have an account?
Account No.
Landlord's Address
Are you responsible for Service?
Tank Size
No. of Occupants
Current Volume in Tank
Home Square Footage
Would you like automatic delivery?
Type of Home Heating Fuel
Clean HeatBioHeatWinter BlendKeroseneI Don't Know
Type of Heating
SteamWarm AirForced Hot Water
Number of Zones
Is water heated by oil?
Hot water heater make
Do you have a free-standing Unit?
Do you have a tankless unit?
Is your hot water storage tank connected to your boiler?
Furnace/Boiler make
Is your house air-conditioned?
Date of last maintenance
Schedule cleaning or ultimate inspection?
When?
Are you interested in a service plan?
Applicant 1:
Employer
No. of Years
Previous address (if < 2 years)
Applicant 2 (if applying jointly):
Applicant #1 Signature
Date
Applicant #2 Signature
I've read and understand the terms and conditions, and the Peterson Customer Information Handbook.
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