Become a Customer

L&G Propane welcomes new customers. If you would like to experience the peace of mind of having a reliable supplier that provides attentive, proactive service, please fill out the form below.

* = Required Field

Basic Information:
* Applicant's Name: (first, mi, last)	Mr.    Ms.    Mrs.
* Email:
* Social Security #:
Co-Applicant's Name: (first, mi, last)	Mr.    Ms.    Mrs.
Co-Applicant's Social Security #:
* Home Phone Number:	()   -
* Billing Address: (City, State ZIP)
How Long Have You Been At This Address?	years
* Own or Rent?	Own  Rent
* Delivery Address: (City, State ZIP)	Same as billing address.
Mortgage Bank / Landlord: Full Address: (City, State ZIP) Phone Number:	()   -
Previous Address: (If less than 4 year at current address) (City, State ZIP)
How did you hear about us?
Employment Information
* Applicant's Employment:
Address: (City, State ZIP)
Phone Number:	()   -
Years With Company:	years
Position:
Applicant's Previous Employer: (If less than 1 year at present) Address: (City, State ZIP)
Co-Applicant's Employment:
Address: (City, State ZIP)
Phone Number:	()   -
Years With Company:	years
Position:
Credit References
* Bank: Address: (City, State ZIP) Phone: Account #: Account Type:	()   -  Savings  Checking
* Name on Credit Card: Account Number: Expiration Date:	(mm/yy)
Emergency Contact
*Name: (Relative or friend not living with you)
*Address: (City, State ZIP)
*Phone Number:	()   -
Delivery Information
Number of Tanks:	Please make a selection 1 2 3 4 5 6 7 8 9 10
* Tank Size:	gallons
Annual Usage:	gallons
* Current Supplier
Nearest Street:
Delivery Instructions:
House Color:
Estimated Gallons in Tank:	10-30 gallons 30-50 gallons 50-70 gallons 70-90 gallons 90+ gallons
Propane Uses:	Please make a selection Residential Commercial Agricultural Cooking Heat Standby Generator Dryer Space Heater Hot Water Pool Heater Other
Do You Have a Budget Plan?	Yes  No
* Preferred Delivery Type:	Automatic Delivery Will Call
Terms & Conditions
All information provided above is true to the best of my/our knowledge. You have my permission to verify any of the above information. If credit is hereby granted, I/we agree to pay the account in full within the thirty (30) day credit terms. A finance charge of 1 1/2 % per month (annual percentage of 18%) will be assessed on all accounts unpaid in thirty (30) days following the due date. Non compliance with credit terms may result in the disruption and/or termination of propane deliveries. I have read and agree to the credit terms above: * Applicant's Signature:   Date: Co-Applicant's Signature:   Date:
Please check the box to verify:

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