Credit Application

New Account Application

Welcome to Dominick! Use the form below to apply for a new account today. If you have any questions, please call the office.

Already a customer?
If you are an existing customer updating an account to add oil or propane, please enter your account number in the text box below. Note, if you need to update your delivery address, please call the office.

* = Required Field

Customer Information

* Customer Name:
* Phone #:
* Work #:
* Cell #:
* E-mail:
* Confirm E-mail:
How did you hear about Dominick?
Other: (please explain)

Delivery/Service Address

* Delivery Address:

Billing and Payment Information

* Billing Address: Same as delivery/service address

Only enter if you want invoices or other correspondence sent to an address other than the delivery/service address.

* Do you own or rent?

Own        Rent

Employment Information

Years There:
Employer Address:

Service Plans

* I am interested in the following plans: (click all that apply.)
Heating Service Plans
Air Conditioning Service Plans
Oil Heat Maintenance Savings Plan
Air Conditioning Maintenance Savings Plan
ProGuard Tank Protection
None at this time

Delivery Information

* Types of Fuels Used at Home: (click all that apply.)
Oil      Propane      Natural Gas      Other

Home Information

Type of Heat System:(i.e. baseboard heat, hot air heat)

Do You Have AC Units?
Yes    No
If Yes, How Many Units Outside?

Number of Heating Zones:(how many thermostats in your home?)

When Was Last Tune-Up?
Age of Heating System?

Age of House?

* Estimated Size of Home
sq. ft.

Questions / Notes:

Previous Oil Company

Previous Oil Company Name:

* Are you currently enrolled
in a price protection contract?

Yes    No

If yes above, when does it expire?

* Would you like us to cancel your account with your previous Company?
Yes    No


I hereby authorize you or any credit agency employed by you to investigate the references herein listed or any of the other information stated to determine my qualifications for a credit account.

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and answer questions about your credit experiences with me. I have read and agree to the credit terms and the customer responsibilities shown above.

By typing your name in the box below, you are "digitally" signing this document:
* Buyer's Digital Signature:

Social Security #: --

Date: 11/12/19