Dealer Name:  
Dealer Street:  
Dealer City:  
Dealer State:  
Dealer Zip:  
Dealer Contact:  
Dealer Contact Phone:  
Dealer Fax:  
Dealer Email Address:  
Dealer Mailing Address if different from above:  

Does your company have Sub-Dealers? Yes No

(NOTE: A separate form must be submitted for each sub-dealer)
Are you Subsidiary of another dealer? Yes No
If Yes, please provide Parent Company name here:  
Who accepts checks for your company? (Please choose one) We do Our Parent Company
Would your company prefer electronic payment? Yes No

Please enter dealer region (zip codes) that you serve:

(NOTE: Only one entry per line City, State, Zip format EXAMPLE: Salem, MA, 01970)

 

Would your Company like to be a referral dealer? Yes No

(Note: Selecting "yes" to the referal dealer question allows Citizens Energy to assign you customers in your area that do not have an existing oil dealer.)
A) Would you like to be a referral dealer for ALL zip codes you serve? Yes No
B) Would you like to be a referral dealer for ONLY some of the zip codes you serve? Yes No

Please list the zip codes you wish to make referral deliveries in.

 

By submitting this form you are agreeing to the terms and conditions set forth by Citizens Energy. Please Print of a copy of the Dealer Agreement for your records here.