First and Last Name:         SSN:

Date of Birth:

Spouse/SO First and Last Name:     SSN:

Spouse/SO Date of Birth:

Marital Status: MarriedSingleWidowedSeparatedDivorced

Mailing/Street Address:

City/State/Zip:

County:

Physical Address (If different than above) :

City/State/Zip:

County:

Do you Own the Tank? NoYes  If YES, we need proof of ownership, contact us on how to provide this information.

Would you like to be on a Keep Full Route or will you call when you need propane? Keep FullWill CallNot Sure  If not sure, contact office to discuss options

Telephone Number(s)  Home:    Cell:   Other:

Do you own or rent your home? OwnRent

Directions to your location and special delivery instructions:

If renting, please provide landlord's name, address, and telephone:

Nearest relative not living in the same household (Name, Address, Phone):

Previous Fuel Supplier Name:

Reason for Leaving:

How did you hear about Stokes & Congleton?  Who Can We Thank?

Employer (Name, Address, Work Number):

Spouse's Employer:

Bank Information (Name, City):

Bank Account Type: CheckingSavings

Driver's License State:   DL Number:

Please List Three Credit References (Name, Address, Telephone):

Reference #1:

Reference #2:

Reference #3:

Propane Equipment or Appliances Currently in your Home (check all that apply):

Furnace        Gas Pack        Space Heater        Water Heater   

Stove/Oven  Gas Logs         Dryer                    Generator

Other (list all):

Approximate square footage of heated area:

By submitting this form you give Stokes & Congleton, Inc. permission to verify your references and other information provided for the purposes of establishing an account to provide propane gas at the indicated location.