Daniels Energy - New Customer Signup

Thank you for your interest in becoming a Daniels Oil customer. Generations of Connecticut families have come to depend on Daniels' outstanding service. Please assist us in determining the right service for you by filling out this simple online form. Information indicated in *red is required. If you prefer to FAX or mail us your application, just click on the mail or fax icon on the left for a printable version of your application. * First Name: * Last Name: * Account: Joint Single -Company or Organization: *Street Address Line 1: -Street Address Line 2: *City: *State: Connecticut *Postal/Zip Code: -Country USA *Primary Phone Number: *Business Phone Number: -Fax Number: *Email Address: Is your billing address different from the delivery address? Yes No * Do you Rent or Own? Rent Own - Where did you hear about us? Family/friend Website Radio
Mailing Newspaper Other

Your Previous Address
*Street Address Line 1:
-Street Address Line 2:
*City:
*State:
*Postal/Zip Code:
-Country	USA
Your Previous Oil Supplier
- Supplier:
-Street Address Line 1:
-Street Address Line 2:
-City:
-State:
-Postal/Zip Code:
-Country	USA

I hereby state that the information I have provided above is true and accurate to the best of my knowledge. I am requesting oil delivery service from Daniels Oil Co., Inc., and agree to provide appropriate information to implement Daniels Oil service.

Please Provide Name of Co-signer
* Co-signer's First Name:
* Co-signer's Last Name:

Please Enter your Billing Address
-Company or Organization:
*Street Address Line 1:
-Street Address Line 2:
*City:
*State:
*Postal/Zip Code:
-Country	USA

Please Enter your Landlord's Name, Address, Phone Number
*Landlord's Name:
-Company or Organization:
*Street Address Line 1:
-Street Address Line 2:
*City:
*State:
*Postal/Zip Code:
-Country	USA
*Landlord's Phone Number: