New Customer InformationCustomer Name First Last Business NameIf you are a commercial customer please enter the business name instead of customer name.Delivery Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneSecondary PhoneEmail Service InformationDate RequestedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tank Size Requested1241722502883305001,000+Initial Gallons RequestedPlease enter a value greater than or equal to 80.Is there an existing tank on the property?Please Select An OptionYesNoUnsureDo you currently have an account with another propane company?Please Select An OptionYesNoWhich company do you currently have a contract with?Propane Usage and Location InformationDoes the location use propane for any of the following:Check all that apply. Water Heater Primary Heating Secondary heating (supplement to a fireplace, electric heating, etc.) Clothes Dryer Range and/or Oven Pool Heater Other Square Feet Of LocationLocation TypePlease Select An OptionResidenceCommercial/IndustrialIs the location a new construction?Please Select An OptionYesNoIs the electricity on and working?Please Select An OptionYesNoHave all applicable appliances been converted to use propane?Please Select An OptionYesNoUnsureAre all appliances in place and hooked up to the propane gas line?Please Select An OptionYesNoHow Did You Hear About Us?Silver Valley Propane, Inc. does not guarantee a commitment to provide services based on completion of this form nor does Silver Valley Propane, Inc. guarantee that requested tank size, date, or initial gallons will be honored. We reserve the right to refuse service to anyone for any reason allowed by law. After we receive this form you will be contacted to confirm details and to be put on our service schedule.NameThis field is for validation purposes and should be left unchanged.