Service Application

Are you a:

- select one - Residential customer Commercial customer

Name:

Phone numbers:

(please provide at least one phone number)

Home:

Work:

Cell:

Mailing address:

Email address:

Caretaker name (if applicable):

Caretaker phone numbers:

Home:

Work:

Cell:

If you rent, what is your landlord’s

Name:

Address:

Phone number:

Email:

Delivery/service address:

Tank locations:

Address:

Type of Tank -select one- Above ground tank Underground tank

How many tanks do you have at this location?

What is the gallon capacity size of your tank?

Please give us any special instructions:

Who owns the tank? -select one- I own the tank Yates Gas owns the tank It is a metered tank I’m not sure

How will you use your propane? (Check all that apply)

Heating Cooking Hot water Dryer Gas grill
Commercial use Pool heater Other (please describe)

Where is your meter located?:

How many gallons of propane do you use at this location each year?

If you are not sure how many gallons you use, please ask your previous provider for this information.

Please select how you would like to make payments:

Please automatically deduct from my bank account (must provide voided check from the bank account)
checking   savings

Please charge my credit card (Visa, MasterCard, AMEX, Discover)

Please bill me

Terms of Service: No finance charge if paid 30 days from the statement date

I agree