Residential Heating Oil Account Application Step 1 of 5 - Personal Information 20% In order to establish an account with Valley Energy or Capitol Discount Fuel, 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 our Customer Service staff will contact you shortly.Personal InformationName* First Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Type* Home Mobile Office Additional PhoneAdditional Phone Type Home Mobile Office Home Ownership* Own Rent How long at this address?* 1-3 Months 4-12 Months 1-3 Years 4+ Years Former Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Status*Currently EmployedNot Currently EmployedRetired EmploymentCurrent and/or former.Employer* How Long?*1-3 Months4-12 Months1-3 Years4+ YearsEmployer's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse InformationSpouse Name First Last Employer Spouse Address Same as above Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse Phone Payment and Delivery InformationPayment Type* Invoice Billing (pay for each delivery within 30 days) Smart Pay Account (have an even monthly payment) For more information about Smart Pay plans, contact Bill Cleary at information@valleyenergy.org.In what format would you like your bill/invoice? Email Tank Size* 275 550 1000 Delivery Type* Automatic Will Call Heat Hot Water with Oil* Yes No Tank Location* Inside Outside Special Instructions for DeliveriesDescribe Location of Fill Pipe (if facing front of home from the street):*How did you hear about us?* Friend/Neighbor Previous Homeowner Internet Ad Facebook Other Credit Policy and Terms Payments are due upon receipt of invoice. 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. Any account which becomes past due is subject to termination of automatic fuel delivery without notice until the account balance is paid in full. All fuel remains the property of Valley Energy or Capitol Discount Fuel until paid in full. Valley Energy or Capitol Discount Fuel reserves the right to reclaim any fuel not paid in full. 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. A service charge of $25.00 will be added on any check or eCheck returned by a bank. Any out of fuel resulting from non-payment will incur a start-up fee upon delivery. Termination of automatic delivery service must be made in writing. 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. If litigation arises out of this contract, the parties agree Virginia law shall apply and litigation must be filed in the Courts of Loudoun County, Virginia. I accept your offer to deliver my requirements of fuel according to the credit terms above.* I accept Signature* Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged. Δ