Internal HO Enrollment Form

1Admin Info

2Service & Contact Info

Staff Member Name*
How did they hear about us?*
If the enrollee heard about us through a partner organization, they might have a promo code depending on if we're running a promotion with the partner.
Name of Referrer
Other Details
Social media

Date Enrollment Received*
MM slash DD slash YYYY
Name*
First Last
Email*
Phone*
Service Address*
Street Address City State ZIP Code
Billing Address
- Same as service address
Billing Address*
Street Address City State ZIP Code
County*
Supplier*
What does the member use heating oil for?*
Where is the tank located?*
Where is the fill spout located?*
Tank Size*
A standard sized tank is 275 gallons, which is typical for a residential home. Enter “unknown” if the member doesn’t know.
Delivery Schedule*
Delivery Notes
Enter any special notes the member provides related to their oil delivery.
When does the member plan to place their first order?*
MM slash DD slash YYYY
Are you interested in hearing about service contract options from the supplier?*
Member Status*
Enrollment reason*
Phone
This field is for validation purposes and should be left unchanged.

Have questions? Give us a call at 215.413.2122.