Propane Sales Residential Application

Name

This field is for validation purposes and should be left unchanged.

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 Information

Name*

First Last

Email*

Alternative Email

I 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 Name

*If different from name on the appplication.

Primary Phone Type*

Home

Mobile

Office

Can we send service and delivery related texts to your primary phone?*

Yes

No

Additional Phone

Additional Phone Contact Name

Additional Phone Type

Home

Mobile

Office

Fax

Can we send service and delivery related texts to your additional phone?

Yes

No

Address*

Street Address Address Line 2 City 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 State ZIP Code

How did you hear about us?*

Social Media

Internet Search

Google Ad

Postcard

Builder

Realtor

Previous Homeowner

Friend/Neighbor

Saw a Valley Energy truck

*Select One

Name of Friend Or Neighbor*

We want to make sure we can thank them!

Employment Status*

Employment

Current and/or former.

Employer*

How Long?*

Employer's Address

Street Address Address Line 2 City State ZIP Code

Spouse Information

Spouse Name

First Last

Spouse Employer

Spouse Address

Same as above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse Phone

Rental Addendum

All customers who rent their property are required to complete the following Rental Addendum.

Tenant Name*

First Last

Tenant Email*

Landlord Name*

First Last

Landlord Email*

Landlord Phone Number*

Landlord Phone Type*

Landlord Secondary Phone Number

Landlord Secondary Phone Type

Who is responsible for service/repairs to the heating system?*

Lease Start Date*

Lease End Date

Move-In Date

Rental Agreements

I 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

Tenant Name*

First Last

Tenant Signature*

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*

CAPTCHA

Application - Propane Buy-Back

Personal Information

Employment

Spouse Information

Payment and Delivery Information

Rental Addendum

Rental Agreements

Credit Policy and Terms

Phone Numbers

Email Address

Address