Tank Lease Agreement
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Minimum gallons per year for tank size indicated
Min. gallons per year / tank size
Directions to address
Equipment owned by:
Customer
CC Propane
Consumer Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home / Cell #
*
-
Area Code
Phone Number
Email
*
example@example.com
Employer
Work Phone
-
Area Code
Phone Number
Do you own or rent your home?
*
Own
Rent
Landlord Name
First Name
Last Name
Landlord Phone
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I agree to a credit check. Please initial.
*
Type in initials
Signature
*
Submit
Should be Empty: