New Customer Application

Thank you for your interest in becoming a customer of Roman Oil Company.  To initiate the application process, please complete the following form.  A member of our staff will contact you to review the information you have provided. 

If you would prefer to initiate the application process over the phone,contact us via telephone at 203-235-3371 during regular business hours to speak with a Roman Oil representative.


Personal Information:

Tell us about yourself:
(* denotes required fields)
Name*
         Joint Name
Address *
Address
City *
City
Home Phone *
Home Phone
Email Address
Email Address
Social Security #
Social Security #
Employer
Employer
Work Phone
Work Phone
Referred By

Bank Reference - One Required
Bank Name
Account Type
Address
Account Number
Do you own or rent the address listed above?
If you rent please reference the landlord's name and phone #

Do you want to be on automatic delivery?
You must be on automatic delivery in order to have a service contract
If yes, please indicate how much oil is in your tank.

Are you actively enrolled in the United States Armed Forces at this time?


By completing this application you hereby agree that all information contained herein is true to the best of your knowledge. This information is provided for the purpose of obtaining credit. You agree with our terms which are payment of all invoices unless otherwise specified and are due and payable within 30 days from the date of the invoice. A late penalty interest charge of 1.5% per month (18% per annum) shall be payable on all accounts unpaid after 30 days. You also agree to pay for all collection cost and reasonable attorney's fees.

Comments:


31 Bee Street
Meriden, CT 06450
M - F: 8 am to 4 pm
t: 203-235-3371
f: 203-235-7895
License #302584
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