Residential Propane Account Application Step 1 of 5 - Personal Information 20% 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.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 State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse Phone Payment and Delivery InformationIn what format would you like your statement? Email In what format would you like your bill/invoice? Email Invoice 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.Tank Ownership* Company Customer If Tank Ownership is "Company" I agree to the terms of the propane tank lease agreement and acknowledge that Automatic Delivery is required for all company owned tanks.Delivery Type* Automatic Will Call (Automatic Delivery is required for the Smart Pay plan)Tank Size* 1000 500 325 250 120 Cyl Facing the house (from the street), please indicate the tank location:* Right side Left side Rear of house, on right Rear of house, on left Propane Used For:* Furnace/Boiler Water Heater Fireplace Generator Dryer Range Pool Other Special Instructions for DeliveriesHiddenReferral Source How did you hear about us?* Friend/Neighbor Previous Homeowner Internet Ad Facebook Builder Saw a Valley Energy truck 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 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 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 gas 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