Hinds Energy welcomes new customers. If you would like to open an account with us, please fill in the electronic form below and send us your information. A member of the Hinds Energy team will contact you shortly. We look forward to serving our friends in Susquehanna County and Wyoming County, PA and parts of the Southern Tier of NY and allowing them to experience first-rate heating and air conditioning services, quality heating oil, propane and other fuels, and much more.

This application is not a credit application.

* = Required Field

Your Information:

* Name:

Mr.

Ms.

Mrs.

Date of Birth:

* Billing Address:

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

* Delivery Address:

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Directions to house:

Own or Rent?

Own

Rent

Years at Address

Fuel Type

Fuel Oil

Propane

Oil Tank Location

Inside

Outside

Previous Oil User?

Yes

No

Previous / Current Oil Supplier

Tank Owner

Customer Owned

Owned By Another Supplier

Tank Size

Fill Pipe Location

Use of Fuel

Heat

Water Heater

Cooking

Space Heater

Drying

Pool

Other

*Phone:

Work:

Mobile:

*Email:

Previous Address
(If less than 5 years at current):

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Previously Own or Rent?

Own

Rent

Years at Address

How Did You Hear About Hinds Energy?

Employment Information:

Employer

Address

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Phone:

Position

How Long Employed

Landlord Information:

Landlord

Landlord's Address

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Landlord's Phone:

Co-Applicant Information:

Co-Applicant Name:

Mr.

Ms.

Mrs.

Date of Birth

Billing Address

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Years at Address

Previous Address
(If less than 5 years at current):

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Years at Address

Phone:

Work:

Mobile:

Email

Co-Applicant's Employer

Address

AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Position

How Long Employed

*Applicant Signature:

*Date:

Do You Agree