Gas and Oil

Bursaw delivers what others promise...

Forms

Residential Propane Account Form

Primary Account Holder
*Name:
*SSN:	- -
*Home Phone:	() -
Cell Phone:	() -
Secondary Account Holder
Name:
SSN:	- -
Home Phone:	() -
Cell Phone:	() -
Delivery Address Information
*Street:
(Optional) Street:
*City:
*State:	*Zip:
*Rent or Own	Rent \| Own
*Landlord's Name:
*Landlord's Phone:	() -
*Statement Preference:	Mailed \| Emailed
*Email Address:
Mailing Address Information (Mailing address same as delivery)
*Street:
(Optional) Street:
*City:
*State:	*Zip:
Employment Information
Primary Employer ( Add Second Employer)
*Primary Employer:
*Street Address:
(Optional) Address:
*City:
*State:	*Zip:
Second Employer
*Secondary Employer:
*Street Address:
(Optional) Address:
*City:
*State:	*Zip:
*Delivery Options
	Automatic Delivery (We take the hassle out of heating your home or business by monitoring your usage. We use a computerized degree-day system to ensure our customers stay warm. Factors such as weather, burner efficiency, and customer usage are analysed by Bursaw to ensure you receive your propane in a timely manner.) Will Call (Customers who choose this option need to give a 48hr minimum notice for delivery and call when tank is at ¼ full.)
*Payment Options
	30 Day Charge C.O.D. Payment
Date of First Delivery:	*Tank Size:
*Current Propane Level:
*Do you own the tank?	Yes \| No
Tank serial #
Delivery Instructions

*Fill Location
(Relative to the street)
Optional Information
Propane Heated Hot Water?	Yes \| No
Propane Heated Pool?	Yes \| No
Propane Fireplace?	Yes \| No
Propane Cooking Equipment?	Yes \| No
Central AC?:	Yes \| No
Date of Last Heating Equipment Cleaning:
Propane Equipment (Up to 5))
Equipment Name/Type:	Equipment Serial #:
Equipment Name/Type:	Equipment Serial #:
Equipment Name/Type:	Equipment Serial #:
Equipment Name/Type:	Equipment Serial #:
Equipment Name/Type:	Equipment Serial #:
Terms of Agreement: There shall be a Finance Charge of 18% per annum remaining on all unpaid statments for a period of 30days or more from receipt of product. Above account agrees to pay all reasonable costs, including reasonable attorney's fee, incurred by Bursaw Gas and Oil Inc. of Acton, Massachusetts. THE ABOVE INFORMATION IS FOR THE SOLE PURPOSE OF OBTAINING CREDIT & IS WARRANTED TO BE TRUE. I/WE HEREBY AUTHORIZE Bursaw Gas and Oil Inc. TO INVESTIGATE THE REFERENCES LISTED PERTAINING TO MY/OUR CREDIT AND FINANCIAL RESPONSIBILITY.
* I accept to the terms and agreement of this form.
*Initial of Primary Holder:
*Initial of Secondary Holder:
Timestamp:
IP Record:

Forms

Residential Propane Account Form

Terms of Agreement: