New Customer

Fill out the New Customer Application below and the Signed Release Authorization Form in full. In order to receive future fuel deliveries on a credit basis, the Signed Release Authorization Form must be returned to me along with your Application as soon as possible. Even if you choose to stay cash-on-delivery (COD), please return the fully filled out and signed Application (front page) to me so I am sure I have all your information correct. If the Signed Release Authorization Form (2nd page) is not returned to me before your next delivery, you will be based on a COD service. On the Signed Release Authorization Form, just fill in the areas that are notated with an asterisk.

Please take the Signed Release Authorization Form into your bank and have them fill in the bottom portion (date opened, account in good standing, any NSF’s, and name of bank representative completing form).

If you have a list of creditors that you do business with and would rather have us call them, please submit it with this application.

Thank you for your time!
Joanna, Accts. Receivable
717-528-4132
Joanna@eandbtransportation.com

First Name*

Last Name*

Address*

City*

State*

Zipcode*

Phone number*

Email Address*

Property Type* ¹

Tank size (gallons)*

Heat water w/ oil*

Fuel Type*

Refill Frequency*

Driver's License No.*

Photo or Scan of License*

Employer Information:

Name*

Phone number*

Credit Reference:

Name

Relation

Phone number

Special Directions/Instructions

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Any additional information

By checking this box, I acknowledge that I am responsible for this accountAgree

Please leave this field empty.

Renters: Cash-On-Delivery (COD) – Must pay for fuel oil when delivered.
Homeowners: Must pay for 1st delivery and then billed upon approval.

New Customer

Landlord Information:

Employer Information:

Credit Reference: