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Oil Order Form

Please provide the following contact information:

 
Account Number (if known)
Amount Ordered
(100 Gallon Min.)
Date requested for delivery:
Type of Fuel:
 
 
First Name
 
Last Name
 
Address
 
Address 2 (optional)
City
 
County
Zip Code
   
State
 
Home Phone (10 digits)
   
Cell Phone (optional):
Work Phone (optional)
 
Email Address
   

 

 

 

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Valley Energy • 115 East Main Street • Purcellville, Virginia 20132 • (540) 338-6457 • Fax: (540) 338-6401