Request for Service / Credit Application

Social Security Number:
(not required unless applying for credit)

Current address

Address:

City:

State:

Zip:

Prior address

Address:

City:

State:

Zip:

Phone:

Best Time To Contact You:

Do you currently use propane? Select One Yes No

If yes, Who is your existing supplier?

Current tank size? If unknown please type unknown

Do you have an above ground tank? Select One Yes No

Do you have an underground tank? Select One Yes No Not Sure

How do you use or plan to use propane?

Central heating & air conditioning? Select One Yes No

Space heating? Select One Yes No

Water heating? Select One Yes No

Gas logs/fireplace? Select One Yes No

Cooking? Select One Yes No

Dryer? Select One Yes No

Generator? Select One Yes No

Gas Grill? Select One Yes No

Pool Heater? Select One Yes No

If desired, in the box below enter a detailed description of your service request or add general comments.

Authorization to check credit

Everything I have stated in this application is correct to the best of my knowledge. By submitting this application along with my social security number, I authorize Mrohs Gas Inc. to check my credit and employment history with the major credit bureau of their choice.