New Customer Application

New customers, please fill out the easy-to-use application form below for propane, heating oil or kerosene delivery service. Existing customers please proceed directly to the order page. Please note – payment information is not needed to fill out the application. We will arrange payment with confirmation of delivery. We thank you for your business and look forward to serving you.

Fuel Type Needed*
Name*
First Last
Order Type*
Federal Tax ID Number*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Employer*
Fill Options*
Size of Tank
Tank Status
Payment Plan*
Appliances Using Gas
- Furnace
- Hot Water
- Gas Logs
- Cooking
- Other
Select all that apply
Home Information
Years at Current Residence
House Square Feet
Do you Rent or Own*
Owner's Name
Owner's Phone
I certify the above information is correct and authorize Couch Oil Company to use the provided information.*
- Yes
- Subscribe To Newsletter
Comments
This field is for validation purposes and should be left unchanged.

New Customer Application

Home Information