Please note: This information may be used to check your credit record at Equifax Information Services. Step 1 of 2 0% Primary CustomerName* First Last Phone*Alternate PhoneEmail Current Employer Birthdate (mm/dd/yyyy)* MM slash DD slash YYYY Have you already contacted Clearwater Propane about this service?* No. This is my first contact Yes. I have already spoken to someone Secondary Customer (if applicable)Name First Last PhoneEmail Current Employer Birthdate (mm/dd/yyyy) MM slash DD slash YYYY Service InformationService Address* Street Address City County State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address(if different) Street Address City County State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you own or rent this property?* Own Rent What is the landlord's name? What was the name of the previous owner? Is there a Clearwater Propane tank on this property?* Yes No I don't know Electric ProviderDo you receive Electric Service from Clearwater Power?* Yes No I don't know How will you use propane at this location?*(Check all that apply) Primary Heat Cooking Backup Heating Water Heating Clothes Drying Shop Heat Pool Heat Motor Vehicle Fuel Additional Winter Usage Other How would you prefer to receive invoices/statements? I would prefer to receive statements/invoices electronically by Email I would prefer to receive paper statements/invoices by mail Consent* I understand that my credit may be checked.By checking the box above and submitting this application, I understand that my information may be used to check my credit at Equifax Information Services.