Residential Application

Primary Account Holder's Information

Name*

SS#*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your delivery address the same as your mailing address?*

Yes

Delivery Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone*

Email Address*

Employer Name*

Employer Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Years Employed*

Work Phone*

If Spouse or Joint Account: Second Account Holder's Information

Name

SS#

Cell Phone

Email Address

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Years Employed

Work Phone

Emergency Contact: Name & Phone Number:

All Applicants - Complete rest of information below & sign.

How long at delivery address listed above?*

Years

Months

Zero Time

If Zero time above, please clarify*

Just moved in

Will be moving in on

Date*

Prior address (If less than 1 yr at delivery address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check which one applies at the DELIVERY ADDRESS listed above*

I Own Property.

I Rent Property.

Previous property owner's name*

Landlord's Name*

Landlord's Phone*

Landlord's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Previous propane supplier delivery address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is there a tank at the delivery location?*

Yes

No - I need a tank set

What size is the tank?*

500 gallon

1000 gallon

Other

List*

Who owns the tank?*

I own

Landlord owns

B&B owns

Another Company Owns

What size of tank do you want set?*

500 gallon

1000 gallon

Other

List*

Propane will be used for: (check all that apply)*

Furnace

Dryer

Gas Fireplace

Stove

Hot Water Heater

Other

List*

# in household (to assist in calculating usage)*

Do you burn wood?*

Yes

Do you have a wood burning fireplace?*

Yes

How did you hear about B&B Propane?

Consent*

I (we), the undersigned individual(s), hereby authorize B&B Propane to obtain my (our) credit report to assist in making necessary informed credit decisions and understand my (our) report may be obtained anytime to make credit decisions regarding my (our) account. I (we) recognize credit history may be a factor in any credit decisions. I (we) understand B&B Propane may report to credit agencies my (our) account information once established. By signing below, I (we) agree to the terms and conditions.

Signature*

Date*

Signature

Date