New Customer Sign-Up Form - Heating Oil
Date
*
Completed By
*
Account Number
Customer Type
*
Residential Heating Oil
Residential Propane
Commercial Propane
Commercial Wholesale Propane
Voucher
Other (Explain in Notes)
First Name
*
Last Name
*
DBA
FEIN/Tax ID
Sales Code
*
GL/Bulk Plant Number
*
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 or Province
*
Select One
Alaska
Alabama
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Arizona
California
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Connecticut
Delaware
Florida
Micronesia
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Idaho
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Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
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Marianas
Mississippi
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New York
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Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip or Postal Code
*
County
*
Is mailing address different than address listed above?
Please Select
Yes
No
Route (for home heat)
Forms to receive via Email/Fax
Please Select
Invoice
Statements
Other (List in Notes)
Pricing
Tank Size
*
Where is your heating oil tank located?
*
Please Select
Outside
Basement
Garage
Tank Ownership
*
Please Select
Customer Owned
Lykins Owned
Tank Type
*
Please Select
Above Ground
Underground
Delivery Pattern
*
Please Select
VIP Autofill
Will Call
Product Type
*
Please Select
#1 Heat Oil - Kerosine
#2 Heat Oil
Propane
ECOHDD
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)
*
Additional Notes
Internal Communication