Email address(Required) Account Number(Required) Account Name(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone Number(Required)Mobile NumberNumber of Gallons Contracted(Required)Price(Required)$ 2.69 per gallon over 300 gallons - OR - $ 2.74 per gallon under 300 gallonsTaxIf unsure of your tax, please contact our officeTotal Paid(Required)Method of Payment(Required) Cash Check Credit/Debit Card **** Due to protecting our customers credit/debit card information, we ask that you no longer send us your credit/debit card information in the mail. If you are paying by Credit/Debit Card please include a phone number for us to call and process your payment once we have received your completed contract. Terms and Agreement(Required) I hereby have read & understand the conditions of the Pre-buy program offered by Coosa Valley Propane. I hereby will adhere to the terms of the conditions stated in this contract. I also understand that if for any reason I fail to abide by this contract, my pre-buy program will end and any unused gallons/money will be refunded back to me.Name(Required) First Last Date(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
