Residential Propane Account Application

In order to establish an account with Valley Energy, you must fill out the form below to apply for an account.  You will receive an email confirmation at the email address you provide and the Valley Energy Customer Service staff will contact you shortly.

1 - Personal Information

First Name
 
Middle Int. (optional)
Last Name
 
Social Security #:
 
Email Address
   
Confirm Email Address
     
Address
 
Address 2 (optional)
City
 
State
 
Zip Code
   
 
Home Phone (10 digits)
   
Work Phone (optional)
 
Cell Phone (required)
   
 
Home Ownership
How long at this address?
 
Former Address, City, State, Zip (required)
 
 

2 - Employment (current and/or former)

Employer
 
How Long?
 
Employer's Address
 
 

3 - Spouse Information

Spouse Name
Spouse Employer
Spouse Social Security #
 
Spouse Address
Spouse Phone
 

4 - Payment and Delivery Information

In what format would you like your statement? Check One In what format would you like your bill/invoice? Check One
   
Payment Type - Check One Delivery Type - Check One

If company owned tank, Automatic Delevery required.

Tank Ownership - Check One Tank Size - Check One
If Tank Ownership is Company, I agree to the terms of the propane tank lease agreement.
Propane Used For: Facing the house, please indicate the tank location:
(required)




 
Special Instructions for Deliveries: (optional) Referral Source:

5 - Credit Policy and Terms

  1. Payments are due upon receipt of invoice.
  2. A late charge may be assessed on all balances over thirty (30) days. This is computed by a periodic rate of 1.5% (which is an annual percentage of 18%) on the portion of the previous balance over thirty (30) days less payments and credits appearing on the statement. An account is considered past due when a late payment charged is assessed.
  3. Any account which becomes past due is subject to termination of automatic fuel delivery without notice until the account balance is paid in full.
  4. All fuel remains the property of Valley Energy until paid in full.  Valley Energy reserves the right to reclaim any fuel not paid in full.
  5. Should past due account(s) require the assistance of a collection agency and/or attorney to obtain payment(s), the credit applicant herein agrees to pay for all costs, including any attorney's fees associated with collection and any subsequent enforcement action.
  6. A service charge of $30.00 will be addedd on any check returned by a bank.
  7. Any out of gas resulting from non-payment will incur a start-up fee upon delivery.
  8. Termination of automatic delivery service must be made in writing.
  9. I hereby authorize you or any credit reporting agency employed by you to investigate the references herein listed or any of the other information stated above to determine my qualifications for a credit account, I also acknowledge receipt of a true copy of the credit terms listed.