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
2 digit month, 2 digit day, 4 digit 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
Signature
*
Print Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Co-Applicant's Signature
Print Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: