New Customer Registration - PROPANE GAS

Last Name:

First Name:

Delivery Address:

Located Between:

City:

State:

Zip:

Billing Address:

City:

State:

Zip:

Home phone:

Work phone:

E-mail:

Former propane supplier:

Date of last delivery:

Do you have a dog in yard?

Do we need a key for gate or door?

Tank size: 20 lb BBQ Tank 33 lb Forklift Tank 50 Gallon 100 Gallon 100x2 Gallons 250 Gallon 300 Gallon 500 Gallon 1000 Gallon

If other tank size please specify:

Approximate propane consumed per year:

Type of delivery:

Do you have an underground propane tank?

Do you own your own propane tank?

Where is your propane tank?

What do you use propane for?

Payment type:

Card type:

Credit Card # (last 4 digits):

EXP. Date:

Automatic Credit Card Deduction on all deliveries:

Charge my Credit Card one time (1x):

Your name:

I authorize Pilgrim Propane Group suppliers to deliver my fuel and check my credit.