New Customer

* Denotes Required Field

First Name:*

Last Name:*

E-Mail Address:*

Company Name (If Applicable):

Full Address:*

Best Phone #:*

Additional Phone #:

Do you:*

Own
Rent

Preferred Payment Method:

Credit/Debit Card
Cash on Delivery
Check on Delivery

Products:*

Fuel Oil #2
Propane
Kerosene
Diesel (Off Road) - Ultra Low Sulfur
Diesel (On Road) - Ultra Low Sulfur
Gasoline
Motor Oil & Lubricants
I Don't Know

Tank Size

Tank Location:

Above Ground
Underground

Delivery Type:*

Auto-Fill (requires Credit Application)
No

Annual Consumption (Gallons):

Type of Equipment:

Oil Furnace
Oil Boiler
Gas Boiler
Propane or Gas Furnace
Air Conditioning
Heat Pump (Electric Heat)

Domestic Hot Water with:

Fuel Oil
Propane
Electric
Natural Gas
Other

Would you like information about a service contract which can save you up to 10% in your home energy bill?:

Yes
No

Message or Special Delivery Instructions:

Preferred Company:

Alamance Oil - Alamance County Area
Carolina Fuels - Rockingham / Caswell / Stokes County Area
Berico Fuels - Greater Greensboro Area

Please fill in the above code for security purposes.*