New Customer Sign-Up Form - Propane
Date
*
Completed By
*
Customer Type
*
Residential Heating Oil
Residential Propane
Commercial Propane
Commercial Wholesale Propane
Voucher
Other (Explain in Notes)
Appliances Using Propane
*
Furnace
Water Heater
Cook Stove
Gas Logs
Pool Heater
Space Heater
Generator
Other (Explain in Notes)
Do you have a Heat Pump?
*
Please Select
Yes
No
I don't know what that is
First Name
*
Last Name
*
DBA
FEIN/Tax ID
Sales Code (select)
*
Please Select
1031 - Milford Propane
1079 - Circleville Propane
Salesperson
GL/Bulk Plant Number (select)
*
Please Select
0300 - Milford Propane
0301 Circleville Propane
0310 Wholesale Propane
Business Phone
*
Fax
Email Address
Did customer refuse email?
*
Please Select
Yes
No
Tax Exempt (must provide forms)
*
Please Select
No
Yes (list reason in notes)
Yes, residential in Kentucky
Address 1
*
City
*
State
-- Please Select --
AA
AE
AK
AP
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip or Postal Code
*
County
*
Is mailing address different than address listed above?
Please Select
Yes
No
Route (for home heat)
Product Type
*
Please Select
#1 Heat Oil - Kerosine
#2 Heat Oil
Propane
ECOHDD
Forms to receive via Email/Fax
Please Select
Invoice
Statements
Other (List in Notes)
Locked-In Price if offered
K-Factor if Auto Fill (default to 5 or ask Darin)
*
Non-Heat Adj if Auto Fill (.5 for water heater; .1 for cooking or clothes drying)
*
Tank Ownership
*
Please Select
Customer Owned
Lykins Owned
Tank Type
*
Please Select
Above Ground
Underground
Delivery Pattern
*
Please Select
VIP Autofill
Will Call
Tank Size (select)
*
Please Select
120 gallon
250 gallon
325 gallon
500 gallon
1000 gallon
(2) manifolded 120s
Other (List in Notes)
Tank Size Notes
Sales Alias
*
Please Select
ProHHLyk (Home Heating, Lykins Owned Tank)
ProHHCust (Home Heating, Customer Owned Tank)
ProComm (Commercial)
ProAG (Agriculture)
ProCyl
ProWholesale (Wholesale)
ProTemp (Temporary Heating)
Annual Tank Rental
Anniversary Date of Tank Rental
Driver's Note 1:
Driver's Note 2:
Driver's Note 3:
Account Note 1:
Account Note 2:
Account Note 3:
How did you hear about Lykins Energy Solutions?
Billboard
TV Commercial
Radio Commercial
Sporting Events
Saw a Lykins Truck
Social Media Source
Internet Ad
Mail Piece/Postcard
Phone Book
Friends
55KRC
Broker Deal
Sales Person
Family or Friends
Lykins Energy Solutions Employee
Mail Piece / Postcard
PUCO
Radio
Other
Name of Employee/Sales Rep or Other Notes (if applicable)
*
First Fill Gallons
First Fill Price
Tank Rent
Installation Fees
Other Billing
Tax Rate
Total Initial Billing
Would you like to pay by credit card?
*
Yes
No
Additional Notes
address2