FUEL REQUEST FORM
For non-emergency service requests only

If you are out of oil or kerosene, or you have no heat,
please call 336-299-0531 (Greensboro), 336-887-1960(High Point)
or 336-784-6079 (Winston-Salem) for service.
 

Please fill out the form as completely as possible.
* Fields marked with an asterisk are required.

I am:

  A Current Customer
  Interested in Becoming a Customer

I have:

  A Service Agreement
  No Agreement

Account Number:

* Name:

Address:

City:

State:

Zip Code:

Service / Product:

  Fuel Oil Delivery
  Dyed Kero Delivery

Please provide at least one phone number, and an email address so we may contact you.
** Please make sure your contact information is accurate. **
We respect your privacy.  We will not sell or distribute your contact information.

* Cell Phone or Work Phone:

* Home Phone:

* Email Address:

* Description of Delivery Request:

Comments or Questions:

For security purposes, please type in the submission code you see in the image below:

*

   (Audio file of code)