Pre-Buy Agreement Form

1
Please enter your Heartland Propane account number. * This field is required.You can find this number on your bill or within the online customer portal. If you are not yet a Heartland Propane customer, please call us at (800) 211-9101.
2
About Pre-Buy from Heartland Propane* This field is required.
3
Please select the STATE in which you will receive service.* This field is required.
Kansas
Missouri
Oklahoma
4
Kansas residents: Please select the COUNTY in which you will receive service.
Allen
Anderson
Bourbon
Cherokee
Crawford
Douglas
Franklin
Jefferson
Johnson
Labette
Leavenworth
Linn
Miami
Neosho
Osage
Shawnee
5
Missouri residents: Please select the COUNTY in which you will receive service.
Barton
Bates
Cass
Jasper
Newton
Vernon
6
Oklahoma residents: Please select the COUNTY in which you will receive service.
Craig
Delaware
Ottawa
7
This year's Pre-Buy price is:* This field is required.Click "NEXT" or tap the right arrow to continue.
8
Pre-buy price for calculation* This field is required.
9
How many gallons do you wish to pre-buy for the season?* This field is required.We require a minimum purchase of 225 gallons.
10
Total amount of purchase (including county sales tax):* This field is required.Amount in dollars
11
Please note your total pre-buy purchase amount of ${totalAmount} does NOT include a regulatory compliance fee of $9.43 that will be charged for each delivery.
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Your Name* This field is required.
13
Your Email Address* This field is required.
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Service Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Are you a routed customer, meaning you receive deliveries from Heartland Propane without having to request them?* This field is required.
YESNO
16
Would you like to become a routed customer and start receiving deliveries automatically based on your estimated usage?
YESNO
17
Are you enrolled in paperless billing?* This field is required.Go paperless and receive your statements in a faster, more secure way.
YESNO
18
How do you plan to pay your pre-buy total of ${totalAmount}? Please note that if making multiple equal payments, you MUST enroll in Auto Pay. Auto Pay deductions will occur on the 25th of each month.
One payment received by Sept. 25
Two equal monthly payments (First payment must be automatically deducted by Aug. 25)
19
Are you enrolled in Auto Pay?* This field is required.
YESNO
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You must enroll in Auto Pay in order to pay for your pre-buy gallons in installments. After you submit this form, please click the link that will be presented to open the Auto Payment Authorization Form.

Please note that when you enroll in Auto Pay, ALL of your future payments for service work or deliveries will occur automatically on the 25th day of the month -- not just the payments for your pre-buy gallons.
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Signature* This field is required.By signing your name and clicking "Submit", you agree to pay the total pre-buy amount of ${totalAmount} under the following terms: {howDo}. If paying in installments, you agree that you will enroll in Auto Pay using the Auto Pay authorization form. A link to this form will be presented upon submission. (If on a phone or tablet, use your finger to draw your signature in the space below. If on a computer, use your mouse or touchpad to draw your signature in the space below.
Clear
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Installment amount (two payments)
23
Installment amount (three payments)
Should be Empty: