Energy Order Form - Fuel Hensall Co-op

* Name

* Address This is your mailing address.

* Service Address The location where the delivery is to be made

E-mail

* Phone Number

Account Number (if known)

Driver (if known)

* Product Select the type(s) of fuel needed, and please indicate fill or amount needed.

Coloured/Dyed Diesel - FILL
Coloured/Dyed Diesel - AMOUNT (indicate in notes below)
Clear Diesel - FILL
Clear Diesel - AMOUNT (indicate in notes below)
Premium Gas - FILL
Premium Gas - AMOUNT (indicate in notes below)
Furnace oil - FILL
Furnace oil - AMOUNT (indicate in notes below)
No lead gasoline - FILL
No lead gasoline - AMOUNT (indicate in notes below
Ethanol - FILL
Ethanol - AMOUNT (indicate in notes below)

Amount(s) of product(s) ordered. Please state the $ or litre amounts wanted for each product.

Date needed

Other notes/messages

Fuel Order Form