Residential Heating Oil Account Application Step 1 of 6 - Personal Information 16% FacebookThis field is for validation purposes and should be left unchanged.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 Alternative Email *optionalI acknowledge that Valley Energy will send statements and invoices will be sent to the email address entered above using a paperless billing system.*All new and previous statements, bills, and online payments may be viewed on MyFuelPortal. If you do not have access to an email address and require statements and bills to be mailed to your address on file, please contact Valley Energy directly. I agree Which email should billing statements and invoices be sent to?* Primary Email Alternative Email Both Primary Phone*Primary Phone Contact NameIf different from name on the application.Primary Phone Type* Home Mobile Office Can we send service and delivery related texts to your primary phone?* Yes No Valley Energy promises to never send any promotional marketing related text messages.Additional PhoneoptionalAdditional Phone Contact NameIf different from name on the application.Additional Phone Type Home Mobile Office Can we send service and delivery related texts to your additional phone? Yes No Valley Energy promises to never send any promotional marketing related text messages.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 Home Ownership* Own Rent How long at this address?* 1-3 Months 4-12 Months 1-3 Years 4+ Years If you currently do not occupy this address, when is your tentative move-in date?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 How did you hear about us?* Social Media Internet Search Postcard Friend/Neighbor Previous Homeowner Realtor Saw A Valley Energy Truck Name of Friend or Neighbor*We want to make sure we can thank them with account credit! https://valleyenergy.org/refer-a-friend/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 EmployerSpouse 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 NumberCan we send service and delivery related texts to the spouse phone number? Yes No Valley Energy promises to never send any promotional marketing related text messages. 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, visit our website at valleyenergy.org/smartpayValley Energy requires all new residential oil customers to keep a valid card on file. Your card is only charged after a delivery. You can update your card anytime by calling 540-338-6457 or on the online portal.* I authorize Valley Energy to keep my card on file and automatically charge it for each oil delivery. *pending credit approval Delivery Type* Automatic Will Call Automatic Delivery is required for the SmartPay planTank Size* 275 550 1000 Current Tank LevelIf Known - Example: 1/2 tank full or 1/4 tank full Heating Oil Usage:* Primary Heat Backup Heat Do you use heating oil to heat hot water?* Yes No Tank Location* Inside Outside Please Describe Tank Location:*For example: outside above ground, outside underground, or in basement Special Instructions for DeliveriesDescribe Location of Fill Pipe (if facing front of home from the street):* Rental AddendumTo be completed by applicants who selected "rent" on page 1.Tenant Name First Last Tenant Email Landlord Name* First Last Landlord Email* Landlord Phone Number*Landlord Phone Type*MobileHomeOfficeFaxUnknownLandlord Secondary Phone NumberLandlord Secondary Phone TypeMobileHomeOfficeFaxUnknownWho is responsible for service/repairs to the heating system?*LandlordTenantLease Start Date* Lease End Date *if known*Move-In Date* Rental AgreementsI consent to keeping a credit card on file to be run automatically for each delivery.* Agree I will notify Valley Energy 30 days prior to lease termination and ensure my account is paid in full.* Agree I am aware that any deliveries required prior to moving out must be scheduled a minimum - of 5 business days in advance.* Agree Printed Tenant Name* First Last Tenant Signature*Your NameYour NameYour NameYour Name 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 2% (which is an annual percentage rate of 24%) on the portion of the previous balance over thirty (30) days less payments and credits appearing on the statement, plus $50 per month late fee. An account is considered past due when a LATE PAYMENT CHARGE 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 until paid in full. Valley Energy 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 all costs, including any attorney’s fees (40% of outstanding principal balance), associated with collection and any subsequent enforcement action. The applicant also agrees that Virginia law shall apply, and litigation must be filed in the Courts of Loudoun County, Virginia.. A service charge of $35.00 will be added on any check or eCheck returned by a bank. I accept your offer to deliver my requirements of fuel according to the credit terms above.* I accept Full Name* First Last Signature*Your NameYour NameYour NameYour NameCAPTCHA
