Dyer Energy

252 Britton Street Raynham, MA 02767

Phone: 508-822-3423≡Fax: 508-821-3368≡Info@DyerEnergy.com

Customer Information Form

General Information

First Name

Last Name *

Email *

Home Phone Number *

Work Phone Number *

Extension

Cell Phone Number *

Billing Address

Billing Address *

Billing Address 2

City *

State

Zip Code *

Delivery Address
(If different form billing address)

Address

City

State

Zip Code

Heating/Air Conditioning System Information

Type of Heat *

FHW	FWA
STEAM	HYDRO AIR

Domestic Water *

Electric	Gas
Tankless	Oil - Direct
Oil - Indirect

Fill Location *

Front	Back
Left	Right

Current Supplier

Number of Tanks *

Tank Size (in gallons) *

Current Level *

When would you like your next delivery? *

Credit Application

Do you own or rent your home *

If you own your home, how long have you owned it? *

Current Employer *

How long have you been employed at your current employer? *

What is your preferred method of payment? *

Upon Receipt of Invoice	Master Card
Visa	Discover

Credit Card Number *

Expiration Date *

Social Security Number *

Co-Applicant Information

Co-Applicant First Name *

Co-Applicant Last Name *

Co-Applicant Social Security Number *

The above information is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize Dyer Energy and affiliated companies to obtain credit data from any credit agency. In addition, I/We hereby authorizeDyer Energy to deliver heating oil to my home on automatic delivery.

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