New Customer/Credit Application"*" indicates required fieldsStep 1 of 520%PLEASE NOTE: Submitting this form does not ensure immediate service. The process can take up to 2 weeks to complete.Account Type*Note: A social security number must be provided for chargeable accounts. Payment Upfront ChargableName* First Last Social Security Number*Signature*I agree to allow Nelson's Oil & Gas, Inc. to obtain a credit report using the social security number that I have provided for the purpose of establishing a chargeable account for utilities provided.Phone*Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same? Yes NoMailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Spouse's Name First Last Spouse's PhoneSpouse's Email Spouse's Social Security NumberSignature*I agree to allow Nelson's Oil & Gas, Inc. to obtain a credit report using the social security number that I have provided for the purpose of establishing a chargeable account for utilities provided.Current EmployerEmployerJob TitlePhoneSpouse EmployerJob TitlePhoneDo you own your home? Yes No, we rent this propertyLandlord's NamePhoneDo you own your tank? Yes No, the tank is leasedPrevious SupplierTank SizeWhat products / services are you interested in?Please check all that applyProducts* Propane Delivery Gas/Diesel Delivery Fuel Oil Cardlock (HS)Propane needed for* Tank set needed Furnace Water Heater Stove Fireplace GeneratorPropane Services* Keepful Call In Budget PrebuyGas/Diesel Services* Keepful Call In BudgetPayment InfoWould you like to Auto Pay with a check or credit card? Yes NoPLEASE PROVIDE A VOIDED CHECK OR CALL IN WITH A CREDIT CARD NUMBER TO KEEP ON FILE.Would you like to have invoices emailed to you? Yes NoEmail Would you like to Opt In for text communications from Nelson's? Yes NoCell PhoneCredit TermsNET DUE 30 DAYS FROM INVOICINGFINANCE CHARGES WILL BE APPLIED TO PAST DUE ACCOUNTSCREDIT MAY BE CHECKED THROUGH CREDIT BUREAU OF RAPID CITYConsent* I agree to the credit terms listed above.SignatureDate MM slash DD slash YYYY CAPTCHAΔ
