Check All That Apply*

Property Owner

Tenant

Landlord

Property Manager

Name*

Billing Address*

City and Province*

Postal Code*

Fuel Delivery Address (if different from billing address)

Date of Birth (yyyy/mm/dd)*

SIN

Employer's Name, Address*

Previous Home Address (if less than one year at current)

Cell or Home Phone Number*

Work Phone Number

Email

Delivery Instructions

Propane Tank Ownership*

New Installation - rental tank

Change suppliers - rental tank

Customer-owned propane tank

Other

Previous Suppliers Name or Name of Propane Equipment Installer (if applicable)

Select a Delivery Type*

Automatic Delivery (recommended)

Will Call (advanced notice required)

Propane Tank Size

1 X 420 lb

2 X 420 lb

3 X 420 lb

4 X 420 lb

500 g

1000 g

Other

Delivery and Propane Tank Location(s)

Front of building

Right side of building

Back of building

Left side of building

Other

Amount of Fuel in Tank

Empty

1/4

1/2

3/4

Full

Propane Is or Will Be Used For

Furnace

Water heater

Fireplace

Range

Generator

Other

Type of Water Heater

Electric owned

Electric rented

Propane owned

Propane rented

Other

I have read and accept the general terms and conditions of the supply agreement. I consent to the receipt and exchange of credit and other information about me, including information contained on this agreement with any credit bureau or credit reporting agency and any other person whom I have or propose to have financial dealings with from time to time. I understand that this information may be used for the purpose of establishing and maintaining my financial relationship with Francis Fuels Ltd as permitted by law. I also confirm the above personal and/ or business information is accurate and true. Francis Fuels can consider this acceptance a true signature of authorization. In this section "I" means the Applicant and Co-Applicant. *

Please check this box to indicate that you have read and agree to the General Terms and Conditions and to the terms above.

Propane Fuel Delivery Account Application

Applicant and Propane Delivery Information