Bursaw delivers what others promise...

Forms

Residential Propane Account Form



Primary Account Holder

- -
() -
() -

Secondary Account Holder

- -
() -
() -

Delivery Address Information

Rent | Own
Mailed | Emailed


Mailing Address Information (Mailing address same as delivery)



Employment Information

Primary Employer ( Add Second Employer)


*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 ΒΌ full.)




*Payment Options

30 Day Charge  
C.O.D. Payment  


Yes | No

Delivery Instructions

*Fill Location
(Relative to the street)



Optional Information

Yes | No
Yes | No
Yes | No
Yes | No
Yes | No

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.