Budget Sign-up Form Budget Payment Plan Sign-up* *NOTE: This is a pre-pay plan, NOT a post-pay plan. Account InformationFirst Name* Last Name* Email* Home PhoneCell Phone*Billing Address* Street Address Address Line 2 City State ZIP / Postal Code My Shipping Address is different than my Billing Address Shipping Address Street Address Address Line 2 City State ZIP / Postal Code Tank InformationTank Size* Fill Position*Select One1 O'clock2 O'clock3 O'clock4 O'clock5 O'clock6 O'clock7O'clock8 O'clock9 O'clock10 O'clock11 O'clock12 O'clock(front of your house is 6 O'clock, rear is 12 O'clock)Tank Location* Basement Garage Above-Ground Under-Ground Current Oil Level* Empty 1/4 1/2 3/4 Full Do you Heat your water with oil?* Yes No Would you like Automatic Delivery*?* Yes No *subject to office approval.Would you like Kleen Burn additive with each delivery?* Yes No Kleen Burn increases the heat value by up to 4%, reduces emissions, breaks down sludge, and prevents soot build up in your nozzle and furnace which reduces the need for additional service calls. We highly recommend! The difference is amazing!Home InformationPrevious Oil Usage (gallons)*Time Period*Start DateEnd DatePlease enter start and end dates for the above oil usage.Approximate Size of Home (square feet)*How Many People Live in This Home?*Other Sources of Heat Heat Pump Fire Place Coal Stove Pellet Stove Other What "Other" Heat Source do you have?* Payment Method* Credit Card Check eCheck Comments:Terms & Conditions Green Acres Fuel will sell and deliver to the address shown on this acceptance, your entire requirement of heating oil, subject to any governmental regulations or requisitions, from the date hereof until Green Acres Fuel shall receive in writing a request from you (the customer) to withdraw from this contract, or Green Acres Fuel notifies you (the customer) of discontinuance or transfer of automatic delivery service. Pricing: Subject to a prepaid balance of fuel, the price per gallon shall be Green Acres Fuel's prevailing market price for the place of delivery at the time each delivery ticket is scheduled for delivery (up to three days in advance of delivery), plus all taxes & surcharges, through tank hose connection. Terms: Payment is due on delivery by check, eCheck, or credit card (debit cards not accepted). If customer is not available to pay at time of delivery, an invoice will be left and customer may send payment by check within five days of delivery. If payment has not been received within seven days of delivery, the balance due will automatically be charged to the credit card on file. A 2% processing fee will apply to all credit card transactions. Returned checks are subject to a $70 dollar charge. Customer is responsible for all interest charges & bill collection fees that will be assessed by Green Acres Fuel on delinquent accounts. Delinquent accounts will not receive further deliveries until past invoices & fees have been paid in full. The customer agrees to provide and maintain suitable storage with outside connections that perform properly according to modern industry standards as well as unimpaired access thereto by tank truck at all times at his/her entire cost & risk. Failure to maintain access to fill may result in additional charges being assessed. Customer agrees to defend and hold harmless Green Acres Fuel and any affiliates or related parties from any claims arising from or related to (to any extent) improperly or poorly configured or poorly maintained tanks or connections. Green Acres Fuel shall not be liable for damage of any kind to customer's property, driveway, etc. In no case shall any liability be incurred by Green Acres Fuel for failure to deliver fuel for any reason. This offer, and its acceptance as evidenced by your completion of this form, will, when received by us, constitute the entire contract between us and shall be considered personal, and subject only to written modification or change.I agree to the terms & conditions listed above. I understand that my credit card on file will be automatically charged for the full invoice amount of each delivery, unless I pay cash or check within five (5) days of delivery. If my check is non-negotiable for any reason, the unpaid balance will be charged to my card, along with any applicable fees.Do you agree to the Terms & Conditions above?* Yes, I agree Have A Discount Code? Click "Submit" to complete your contract. A Green Acres Fuel Representative will review the contract and contact you to arrange payment. Thank-you for the opportunity to serve you!