First Name * Last Name * Phone Number * Email * Address * City *-- Select City / Town (required) --AshawayBonnett ShoresBradfordCarolinaCharlestownCoventryCranstonDiesel AccountsEast GreenwichExeterFoster (autofill only)GreenHope ValleyHopkintonJamestownJohnstonNarragansettNorth KingstownRichmondSaunderstownSouth KingstownSterling (autofill only)Voluntown (autofill only)WakefieldWest GreenwichWest KingstownWest WarwickWesterly Zip Code * Payment *-- Select Payment (required) --Credit CardCheckCashCredit Card on File If using Credit Card ** Exp Month *-- Select Month (required) --01 - January02 - February03 - March04 - April05 - May06 - June07 - July08 - August09 - September10 - October11 - November12 - December Exp Year *-- Select Year (required) --2025202620272028202920302031203220332034 Product #2 Heating OilDieselGasoline Fill Location *-- Select Fill (required) --123456789101112 Gallons * or Fill Up Tank Size *-- Select Tank Size (required) --2752x2753302x3305501000Not Listed System Restart ($65) * -- Please Select (Required) --YesNo Residential / Business * ResidentialBusiness Delivery Instructions (required) I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.