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.

Attention Vermont Customers:
Please read the attached Initial Customer Fee Disclosure Document before filling out the form.

* = 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:
* 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:

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: