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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Type*HomeMobileOfficeAdditional PhoneAdditional Phone TypeHomeMobileOfficeHome Ownership*OwnRentHow long at this address?*1-3 Months4-12 Months1-3 Years4+ YearsFormer Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmploymentCurrent and/or former.Employer*How Long?*1-3 Months4-12 Months1-3 Years4+ YearsEmployer's Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Spouse Phone Payment and Delivery InformationIn what format would you like your statement?EmailIn what format would you like your bill/invoice?EmailInvoice 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*CompanyCustomerIf 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*AutomaticWill Call(Automatic Delivery is required for the Smart Pay plan)Tank Size*1000500325250120CylFacing the house (from the street), please indicate the tank location:*Right sideLeft sideRear of housePropane Used For:* Furnace/Boiler Water Heater Fireplace Generator Dryer Range Pool Other Special Instructions for DeliveriesReferral SourceHow 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. I accept your offfer to deliver my requirements of fuel according to the credit terms above.* I accept Signature*CommentsThis field is for validation purposes and should be left unchanged.