Mountain Draft

New Gas Customer Form

New Gas Customer

First Name

Last Name

Company Name/DBA if different

Street Address

City

Mailing Address

City

Mailing Zip Code

Main Phone

Email Address (where you would like invoices emailed)

What date did this business start / assume operations?

Alternate Phone

Is this business:

A new business

New management / owner of an existing business

Will you be purchasing, renting or currently own your cylinders?

Purchasing

Renting

Currently Own (must be approved by Mtn. Draft)

We email invoices and statements. If you have additional contact information for accounting, please provide it here. Name, Phone and email address.

If you own your cylinders how many and what size?

If you are renting cylinders please type your name below signifying that you understand you will be charged $6.50 per month for each small cylinder and $8.50 per month for each large cylinder. This will be invoiced quarterly. (Type N/A if you own or will be purchasing your cylinders)

Auto-Pay is available. Is this an option you would like to set up? If so our accounting team will contact you for this information so that it can be stored safely.

Yes