Propane Tank Lease Form

*Please note the required fields

First name

Last name

Phone (Primary)

Phone (Alternate)

Street Address

Address #, City, State, Zip

Billing Address (if different from Street Address)

Are you a renter?

Yes

If you do not own your residence, this section must be filled out.

If Yes, please provide your Landlord's full name

Address

Address #, City, State, Zip

Landlord's Phone

Emergency Contact (Full Name)

Emergency Contact Phone

Which of the following appliances are fueled by propane gas?

Furnace

Water Heater

Dryer

Stove

If furnace, what year was the furnace installed?

Other Appliances

Lease Agreement

Agreement made and entered into, by and between Dibble Enterprises, Inc., hereinafter referred to as the Company, and (name), hereinafter referred to as the Lessee.

Customer Full Name

The Company and the Lessee agree to the installation of the following equipment and terms:

The Company Reserves the right to increase and decrease the size as it sees fit. The Company may elect to pick up the tank in the event that no LP gas is purchased within a nine (9) month period. Dibble Enterprises, Inc. is the only company that may put gas in or take gas out of a Dibble Enterprises, Inc. tank.

Contracted Accepted by:

Signature

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Date

Month

Day

Year

PROPANE TANK LEASE FORM

*Please note the required fields

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