I'm Interested in Propane

Date*
Date Format: MM slash DD slash YYYY
Your Information
Name
First Last
Service Address*
Street Address Address Line 2 City State ZIP Code
Email
Phone
Account Number (for current Energy Cooperative members, if known)
When is the best time frame to contact you?
- 8:00 am to Noon
- Noon to 5:00 pm
Your Propane Service
What type of service are you interested in?
- Bulk Service (pay all at once)
- Metered Service (monthly payment option)
- Customer Owned
- I don't know
Roughly how may feet from the road is your house?
If you are currently a propane user, how many gallons did you use last year?
- 1-200
- 201-400
- 401-500
- 501-600
- 601+
What is the approximate square footage of your home/building
Please check the appliances in your home/building that use propane.
- Furnace
- Water Heater
- Cook Stove
- Clothes Dryer
- Fireplace
- Generator
- Pool Heater
- Other
Please describe Other
Do you have a heat pump?
- YES
- NO
Do you have a wood burner?
- YES
- NO
How did you hear about our propane service?
- The Energy Cooperative Newsletter
- Bill Stuffer
- Radio
- TV
- Internet Search
- Social Media
- Billboard
- Print Advertisement
- Other
Do you have any other questions or comments?
CAPTCHA

I’m Interested in Propane