Automatic Delivery Application

Please review the Automatic Delivery Terms & Conditions here.

Account #

Name *

First

Last

Email *

Phone Number *

Alternate Phone Number

Delivery Address *

Address Line 1

Address Line 2

City

State

Zip Code

Payment Method *

Credit - MasterCard, Discover & Visa
10 day mail in

License or State ID Number for Main Account Holder

Issuing State

Employer Information

Is the main account holder currently retired? *

Yes
No

Company Name *

Company Phone *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse Information (If Applicable)

Spouse Name

First

Last

Spouse Phone Number

Spouse Employer

Automatic Delivery Questionnaire

1. Do you rent your home? *

Yes
No

Landlord Name *

Landlord Phone Number *

2. How many gallons of heating oil did you use last year?

3. How much oil is in your tank now? Gauge reading or inches

4. Is oil your primary source of heat? *

Yes
No

5. Do you have an alternate source of heat? *

Yes
No

6. Do you use heating oil for hot water? *

Yes
No

7. How many people are using hot water?

8. What color is your house?

9. How many rooms are there in your house?

10. What size is your tank? *

11. Do we have permission to use your driveway? *

Yes
No

12. Is access to the fill pipe restricted in bad weather? (Ice & Snow) *

Yes
No

13. Looking at your house from the street, where is the fill pipe located? *

Choose an option from the drop down

14. If you have 2 tanks, are they connected or separate fill pipes?

15. If there is more than one tank at your house (duplex), are they clearly marked? Explain

16. If you have an underground tank, how old is it?

Anything else we should know?

*

I hereby understand and authorize Discount Oil to charge my Credit Card In the event that I fail to pay my balance or make arrangements within 10 days of my delivery

*

I understand that checking this box constitutes a legal signature

*

By signing below I understand and agree to the terms and conditions set forth in this agreement.

Signature *

Clear Signature

Date / Time *

Date

Time

Please Note: the Social Security Number of the main account holder may be required at the final approval of the application.