Residential Account Request
Dassel's Petroleum, Inc.
Service Requested
*
CARDLOCK
Gasoline
Diesel
New tank
BBQ
Home
RV
If requesting propane, what type of tank?
Existing tank
New tank
n/a
What appliances do you have on propane?
Heater
A/C
Water heater
Range
Pool
Spa
Other
If you requested CARDLOCK, how many cards do you need?
Customer's Name
*
First Name
Last Name
Customer Social Security Number
*
Customer Date of Birth
*
-
Month
-
Day
Year
Date
Customer Cell Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
Customer Email
*
example@example.com
Co-Applicant's Name
First Name
Last Name
Co-Applicant's Social Security Number
Co-Applicants Date of Birth
-
Month
-
Day
Year
Date
Co-Applicants Cell Number
-
Area Code
Phone Number
Co-Applicants Email
example@example.com
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lived at current residence for how long?
Do you own or rent?
Own
Rent
Square feet of home
How many people live in your home?
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Lived at previous residence for how long?
Employer
Position
How long have you been with your current employer?
Monthly Employment Income
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
-
Area Code
Phone Number
Co-Applicant's Employer
Co-Applicant's Position
Co-Applicant's Monthly Employment Income
Co-Applicant's Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Co-Applicant's Business Phone Number
-
Area Code
Phone Number
If self employed, include the name and nature of the business
Self-employed Business Phone
-
Area Code
Phone Number
Nearest Relative - Not living with you
First Name
Last Name
Relative's relationship to you
Relative's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relative's Phone Number
-
Area Code
Phone Number
Credit Reference 1
Firm Name
Credit Reference 2
Firm Name
Additional Comments/Special Instructions
We can not process applications without an appropriate signature
Signature (Due to the pandemic, please provide a formal digital signature to limit face to face interaction with service technicians, dots can't be accepted as a signature.)
*
Print Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Co-Applicant's Signature
Print Name - Co-Applicant
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: