New Customer Propane/Fuel Delivery Form

New Customer Propane/Fuel Delivery Form

Asterisks (*) indicate a required entry for submission
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Address (If different from mailing address.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Product Type:*

PropaneHeating Oil - Stephens City LocationOff-Road Diesel - Stephens City LocationHighway Diesel - Stephens City Location10% Ethanol Unleaded Gas - Stephens City LocationConventional (non-ethanol) Unleaded Gas - Stephens City LocationOther
Payment Type

Budget PlanPre-PayPay Per FillOther
Please list ALL Propane (LP) Appliances and their location in your home/building:
Example: Stove - Kitchen, Dryer - Laundry Room, Furnace - Basement, etc.
Special Notes:
AUTOMATIC FILL/AUTOMATIC DELIVERY

Freedom Ag & Energy will automatically/periodically fill your tank based upon your usage. This option provides you with better prices and forecasted, hassles free deliveries. You no longer have to worry about remembering to schedule a delivery. Please choose your option below:
AUTOMATIC FILL/AUTOMATIC DELIVERY*

YesNo
WILL CALL

I understand I have to call Freedom Ag & Energy to schedule my delivery and that it could take up to seven business days (Monday through Friday) to receive the delivery once I have communicated my need for propane. I further understand that if I run out of propane and need same day delivery necessitating Freedom Ag & Energy making a special trip, there will be an additional charge of $150 (subject to change) added to the normal delivery charges. In addition, I understand that as a “WILL CALL” customer, that should I run out of propane and need an emergency delivery during NON-BUSINESS hours and/or weekends, there will be an additional fee of $200 (subject to change) added to the normal delivery charges. Please choose your option below:
Will Call*

YesNo
ANNUAL SUMMER FILL

Summer is the best time to receive the best price on propane. Take advantage of this option if you wish to always have your tank filled during the summer months. Freedom Ag & Energy will automatically come by once during the summer if you check this box. At that time, we will top off your tank. This will give peace of mind as you go into the winter months and you will receive the best pricing during this time. Please choose your option below:
ANNUAL SUMMER FILL*

YesNo
Date:*
MM/DD/YYYY
Signature:*

Clear
Should be Empty: