Customer Application

Why use us FAQ Contact us

#2 Home Heating Oil Cash Price Today is $2.649/gal.

Please fill form fields

Acct# :

Name:

(Please Print: First, Middle, Last)

Date:

(d,m,y)

Name:

(Please Print: First, Middle, Last)

Delivery Zone:

Delivery Address:	City:	Zip:
Billing Address:	City:	Zip:
Home Phone:	Work Phone:	Cell Phone:
Email Address:
Homeowner:	Tenant:	Landlord:
How long at Present Address?

Present Employer:	Years There?
Description/Color of home/building:	Square Footage:
Single Family:	Duplex:	Apartment:

Present Fuel Supplier

# of Tanks:

Tank Size(s):

If not sure, please measure tank:

Length

Height

Width

Automatic delivery wanted?

Yes

Fill pipe location:

Type of fuel:	#2 fuel	Kerosene	Diesel
Fuel is used for (please check):	Heat Only	Heat & Hot water	Is pipe marked?
Tank Gauge Reading:		0 1/4 1/2 3/4 F

Special Directions or Delivery Instructions:

How did you hear about us? (circle one)

Yellow pages
Newspaper
Website
Coupon Pricing
Mailing
Other:

You are herby authorized to make any investigations concerning my financial standing and /or credit record through any investigative or credit reporting agencies. I/we agree to pay all reasonable costs of collections , including lawyer fees for any outstanding balances.

If you would like to apply for credit, which enables you to have 10 days to pay your balance. Please provide your signature and Social Security Number.

Please check here

Social Security Number:

Date:

"THERE IS A DIFFERENCE"

195 LINCOLN ST. P.O. BOX 837 MANCHESTER, NEW HAMPSHIRE 03105

(603)627-7869/Fax (603)_641-6809 WEB ADDRESS: www.halleoil.com