Date*

Completed By*

Account Number

Customer Type*

First Name*

Last Name*

DBA

FEIN/Tax ID

Sales Code*

GL/Bulk Plant Number*

Business Phone*

Fax

Email Address

Did customer refuse email?*

Tax Exempt (must provide forms)*

Address 1*

City*

State or Province*

Zip or Postal Code*

County*

Is mailing address different than address listed above?

Route (for home heat)

Forms to receive via Email/Fax

Pricing

Tank Size*

Where is your heating oil tank located?*

Tank Ownership*

Tank Type*

Delivery Pattern*

Product Type*

Name of Employee/Sales Rep or Other Notes (if applicable)*

Additional Notes

Internal Communication