Become a Customer

We are pleased to welcome new customers to our "family." We look forward to meeting your home comfort needs. Please complete the credit application below and hit "submit" when you are finished (application is subject to credit check). If you have any questions about becoming our customer, please don't hesitate to call or contact us.

* = Required Field

Company

Reliable Oil & Heat Steve's Fuel Oil Pramer Fuel Darien Fuel

Personal Info

*Name:(First, MI, Last)
Mr. Ms. Mrs.

*Social Security Number:

Spouse Name:(First, MI, Last)
Mr. Ms. Mrs.

Spouse SSN:

*Billing Address:
(City, State, ZIP)

*Delivery Address:
(City, State, ZIP)

Years at Address

*Phone:
() -
Work:
() -
Mobile:
() -
*Email:

Previous Address
(If less than 5 years at current):
(City, State, ZIP)

Previous / Current Oil Supplier

Years at Address

Own or Rent?
Own Rent

Delivery Information

Landlord Information (if applicable)

Landlord:

Landlord's Phone:
() -

Landlord's Address:
(City, State, ZIP)

Employment Information

* Employer:

Phone:
() -

Address:
(City, State, ZIP)

Position:
How Long Employed:

Optional Payment Authorization

I would like to sign up for:
ACH Auto Debit
Credit Card
Neither

Terms & Conditions

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and answer questions about your credit experiences with me.

* I have read and agree to the credit terms and the customer responsibilities shown below.

* I hereby authorize you or any credit agency employed by you to investigate the references herein listed or any of the other information stated to determine my qualifications for a credit account.

*Applicant Signature:

Spouse Signature:

*Date:

* How Did You Hear About Reliable Oil & Heat or Steve's Fuel Oil?

Online Search
Friend/Family
Advertisement
Other
Other: (please explain)