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