Please enable JavaScript in your browser to complete this form.Please review the Automatic Delivery Terms & Conditions here.Account #Name *FirstLastEmail *Phone Number *Alternate Phone NumberDelivery Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePayment Method *Credit - MasterCard, Discover & Visa10 day mail inLicense or State ID Number for Main Account HolderIssuing StateEmployer InformationIs the main account holder currently retired? *YesNoCompany Name *Company Phone *Company Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSpouse Information (If Applicable)Spouse NameFirstLastSpouse Phone NumberSpouse EmployerAutomatic Delivery Questionnaire 1. Do you rent your home? *YesNoLandlord 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 inches4. Is oil your primary source of heat? *YesNo5. Do you have an alternate source of heat? *YesNo6. Do you use heating oil for hot water? *YesNo7. 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? *YesNo12. Is access to the fill pipe restricted in bad weather? (Ice & Snow) *YesNo13. Looking at your house from the street, where is the fill pipe located? *--FrontRearRightLeftGarageOtherChoose an option from the drop down 14. If you have 2 tanks, are they connected or separate fill pipes?--ConnectedSeparate 15. If there is more than one tank at your house (duplex), are they clearly marked? Explain16. 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 SignatureDate / Time *DateTimePlease Note: the Social Security Number of the main account holder may be required at the final approval of the application.Submit