Residential Account Request

Residential Account Request

Dassel's Petroleum, Inc.
Are you a Pacific Pride Cardholder *

Yes No
Service Requested *

CARDLOCK Gasoline Diesel New Tank BBQ Tank Home RV
If requesting propane, what type of tank?

Existing tank New tank Not applicable
Do you own or rent your tank?

Own Rent
What size is your existing tank?
Who is your current supplier?
Do you have propane in your current tank that needs to be transferred?

Yes No
What is the current percentage in the tank?
What appliances do you have on propane?

Heater A/C Water Heater Range Pool Spa Other
If you requested CARDLOCK, how many cards do you need?
Customer's Name *

First Name Middle Name Last Name Suffix
Customer Social Security Number *
xxx-xx-xxxx
Customer Date of Birth *

Month Day Year
Date
Customer Cell Number *

Area Code Phone Number
Driver's License Number *
Phone Number

Area Code Phone Number
Customer Email *
example@example.com
Marital Status *

Married Single
Co-Applicant's Name

First Name Middle Name Last Name Suffix
Co-Applicant's Social Security Number
xxx-xx-xxxx
Co-Applicant's Date of Birth
Co-Applicant's Cell Number

Area Code Phone Number
Co-Applicant's Email
example@example.com
Service Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Lived at current residence for how long?
Do you own or rent?

Own Rent
Square feet of home
How many people live in your home?
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Lived at previous residence for how long?
Employer
Position
How long have you been with your current employer
Monthly Employment Income
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Phone

Area Code Phone Number
Co-Applicant's Employer
Co-Applicant's Position
Co-Applicant's Monthly Employment Income
Co-Applicant's Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Phone

Area Code Phone Number
If self employed, include the name and nature of the business
Self-employed Business Phone

Area Code Phone Number
Nearest Relative - Not living with you

First Name Last Name
Relative's relationship to you
Relative's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relative's Phone Number

Area Code Phone Number
Credit Reference 1
Firm Name
Credit Reference 2
Firm Name
Additional Comments/Special Instructions
Signature

Clear
Signature *
Print Name *

First Name Last Name
Date *

Month Day Year
Date
Co-Applicant's Signature
Print Name
Date

Month Day Year
Date
Should be Empty: