Market Price Contract

MARKET PRICE PROGRAMS
ACCOUNT NUMBER (EXISTING CUSTOMERS)
APPLICANT CONTACT INFORMATION

First NameMiddle NameLast NameSuffix
COAPPLICANT CONTACT INFORMATION

First NameMiddle NameLast NameSuffix
BILLING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your Delivery Address the same as your Billing Address?
DELIVERY ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE NUMBER

Area CodePhone Number
CELL PHONE NUMBER

Area CodePhone Number
EMAIL
example@example.com
DESIRED PROGRAM (MUST SELECT ONE)
ARE YOU A SENIOR CITIZEN? (65+ -$0.02 PER GALLON DISCOUNT)
*COMPLETED & APPROVED CREDIT APPLICATION MUST BE ON FILE.
ADDITIONAL CUSTOMER INFORMATION
NUMBER OF GALLONS TO RESERVE FOR THE SEASON?
IMPORTANT: Please do not underestimate as any gallons used over reserved amount will be billed at market rate.
DELIVERY METHOD PREFERENCE
IMPORTANT: Choose 'A' or 'B' below BUT NOT BOTH.
A. AUTOMATICALLY CHARGE MY CREDIT CARD FOR OIL/BUDGET PAYMENTS. ($0.05 per gallon credit card convenience fee will be added)
B. AUTOMATICALLY DRAFT MY MONTHLY BUDGET PAYMENT FROM MY CHECKING OR SAVINGS ACCOUNT. (Please contact the office for the E-Check or ACH form. A completed & approved form must be on file)
PLEASE ADD THE COST OF ALL SERVICE CONTRACTS TO MONTHLY BUDGET PLAN.
IF I AM THE LANDLORD, THE TENANT HAS MY PERMISSION TO CALL CHESTER COUNTY FUEL OIL FOR SERVICE AS NEEDED.
I CURRENTLY HAVE
TANK SIZE
RESIDENCE INFORMATION
LOCATION OF FILL SPOUT?
TANK LOCATION?
ANY ADDITIONAL DETAILS?
Applicant's Electronic Signature (Type Name)
Co-Applicant's Electronic Signature (Type Name)
Should be Empty:

MARKET PRICE PROGRAMS

ADDITIONAL CUSTOMER INFORMATION