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 EmployerBirthdate (mm/dd/yyyy)* Date Format: MM slash DD slash YYYY Have you already contacted Clearwater Propane about this service?*No. This is my first contactYes. I have already spoken to someoneSecondary Customer (if applicable)Name First Last PhoneEmail Current EmployerBirthdate (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Service InformationService Address* Street Address City County State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address(if different) Street Address City County State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you own or rent this property?*OwnRentWhat is the landlord's name?What was the name of the previous owner?Is there a Clearwater Propane tank on this property?*YesNoI don't knowElectric ProviderDo you receive Electric Service from Clearwater Power?*YesNoI don't knowHow 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 EmailI would prefer to receive paper statements/invoices by mailConsent* 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.