Commercial New Customer Information

Company Name:                                                                                                                       

Delivery Address:                                                                                                                      

City:                                                                             Zip:                                    

Township:                                                                       County:                                    

Tax Identification #:                                                                     

Primary Contact:                                                                       

Is Billing Address the Same? Yes No

If not, Billing Address:                                                                                                  

City:                                                                   State:                 Zip:                          

Office Telephone:                                                                   Fax:                                                  

Desired Method of Delivery: Keep Full Will Call    Desired Method of Payment: NET 30 Prepay

	Product Grade	Tank Size	Tank Color	Tank Location
Gas
Off Road
On Road
Home Heat

Directions:                                                                                                                                              

                                                                                                                                                             

                                                                                                                                                             

NOTE: Commercial Accounts are also required to complete a Credit Application and Tax Status Form

FOR OFFICE USE ONLY Type Of Customer: New Change Farm Use Home Heat Commercial Tax Status: Regular Exempt Resale Industrial Process Government

Date Of Application:                                                    Employee:                                                                     Credit Status Credit Approved Credit Declined Credit Delivery Status Keep Full Will Call One Delivery Quoted Price: $