* Name:
(First, Last)
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Mr. Ms. Mrs.
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Co-Applicant's Name:
(First, MI, Last)
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Mr. Ms. Mrs.
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MAILING ADDRESS INFORMATION: |
* Your Address:
(City, State, ZIP)
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* Phone (Night):
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* Phone (Day):
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* Phone (Delivery):
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Do you own
your own home?
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No Yes For how many years?
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* Email:
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Name of person or organization that referred you to us:
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LANDLORD INFORMATION:
If you rent, please complete landlord's information:
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Landlord's Name:
(First, MI, Last)
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Mr. Ms. Mrs.
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Landlord's Address:
(City, State, ZIP)
|
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Your Previous Address:
If less than 3 years
(City, State, ZIP)
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DELIVERY INFORMATION:
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I Need:
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Immediate Service Immediate Delivery
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* Former Fuel Supplier:
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Date of Last Delivery:
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* Delivery Type:
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Residential Will Call Commercial Will Call
Residential Automatic
Commercial Automatic
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* Delivery Address:
(City, State, ZIP)
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Nearest Cross Street:
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Fill Pipe Location:
|
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* Tank Size:
(in gallons)
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* Oil Type:
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* Annual Usage:
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Burner Brand:
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Do you use oil to
heat your hot water?
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No Yes
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Do you have a dog in the front yard?
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Do we need a key for the gate or the door?
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CREDIT INFORMATION:
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* Social Security No.:
(Applicant)
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Social Security No.:
(Co-Applicant)
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* Employer's Name:
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* Bank Name:
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* Bank Address:
(City, State, ZIP) |
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* Checking Acct. No.:
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* Savings Acct. No.:
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* Your Name:
I authorize Reichert Oil to check my credit rating.
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NOTICE: If we refer your account to collection, your account will increase by 25%. In the event your account is referred to an attorney, you will pay lawyer's fees of 25% of the total unpaid balance in addition to any costs incurred.
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* Please correctly type in the following phrase to verify:
Please type f.u.e.l. without the periods in the box to the right.
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NOTE: To protect your personal information, all data entered into this form will be encrypted during transmission.