Discount Oil of Keene welcomes new customers. If you would like to experience the peace of mind of having a reliable supplier that provides attentive, proactive service, please fill out the form below.

* = Required Field

Basic Information:
* Applicant's Name: (first, mi, last)	Mr.   Ms.   Mrs.
* Email:
* Social Security #:
Co-Applicant's Name: (first, mi, last)	Mr.   Ms.   Mrs.
Co-Applicant's Social Security #:
* Home Phone Number:	()   -
* Billing Address: (City, State ZIP)
How Long Have You Been At This Address?	years
* Own or Rent?	Own  Rent
* Delivery Address: (City, State ZIP)	Same as billing address.
Mortgage Bank / Landlord: Full Address: (City, State ZIP) Phone Number:	()   -
Previous Address: (If less than 4 years at current address) (City, State ZIP)
Employment Information
* Applicant's Employment:
Address: (City, State ZIP)
Phone Number:	()   -
Years With Company:	years
Position:
Applicant's Previous Employer: (If less than 1 year at present) Address: (City, State ZIP)
Co-Applicant's Employment:
Address: (City, State ZIP)
Phone Number:	()   -
Years With Company:	years
Position:
Credit References
* Bank: Address: Phone: Account #: Account Type:	()   -  Savings  Checking
* Name on Credit Card: Account Number: Expiration Date:	(mm/yy)
Emergency Contact
Name: (Relative or friend not living with you)
Address: (City, State ZIP)
Phone Number:	()   -
Delivery Information
* Fill Pipe Location:	left side back of house front of house right side
* Tank Size:	275 gallons 330 gallons 550 gallons 1,000 gallons
Vent Alarm:	Yes  No
Nearest Street:
Delivery Instructions:
Estimated Gallons in Tank:	10-30 gallons 30-50 gallons 50-70 gallons 70-90 gallons 90+ gallons
Do You Have a Budget Plan?	Yes  No
Type of Heat:
Do You Have a Burner Service Plan?	Yes  No
* Previous Supplier
Terms & Conditions
All information provided above is true to the best of my/our knowledge. You have my permission to verify any of the above information. If credit is hereby granted, I/we agree to pay the account in full within the thirty (30) day credit terms. A finance charge of 1 1/2 % per month (annual percentage of 18%) will be assessed on all accounts unpaid in thirty (30) days following the due date. Non compliance with credit terms may result in the disruption and/or termination of fuel oil deliveries. I Have Read and Agree to the Credit Terms Above * Applicant's Signature:  Date: Co-Applicant's Signature:  Date:
Please click the checkbox below to verify: