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? YesNo
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? YesNo
Account No.
Landlord's Address
Are you responsible for Service? YesNo
Tank Size
No. of Occupants
Current Volume in Tank
Home Square Footage
Would you like automatic delivery? YesNo
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? YesNo
Hot water heater make
Do you have a free-standing Unit? YesNo
Do you have a tankless unit? YesNo
Is your hot water storage tank connected to your boiler? YesNo
Furnace/Boiler make
Is your house air-conditioned? YesNo
Date of last maintenance
Schedule cleaning or ultimate inspection? YesNo
When?
Are you interested in a service plan? YesNo
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.
