Form Test - Desrocher

Personal Information

For delivery on:

Account Type*

Residential
Business

Name*

First Last

Phone*

Email*

Delivery/Service Address*

Street Address Address Line 2 City State ZIP Code

Billing address the same as delivery address?*

Yes
No

Billing Address

Street Address Address Line 2 City State ZIP Code

Are you an existing Desrochers Oil Service customer?*

Yes
No

Account Number

Which company do you order from?*

Desrochers Oil
Gils Oil Service
Vadnais Oil

Tank Information

Tank Size*

Tank Orientation*

Tank Fill Location*

Please use the chart below.

House Type*

Order Information

Please note: If more gallons are ordered than can be delivered, the remaining gallons will be applied to the next delivery.

Fuel Type*

Heating Oil Price

Heating Oil Gallons

Kerosene Price

Kerosene Gallons

Please enter a value between 50 and 1000.

Untitled

Fuel Additive?

Learn more about heating oil fuel additives.

Fuel Additive

Delivery Charge

Subtotal

Tax

Total

Total includes sales tax of 5.5%

Special Notes & Delivery Instructions:

Please list if there are any special instructions such as “pipe marked #1”, “Pipe is closest to the street”, etc.

Credit Card

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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