Order Details:

Date
Desired Delivery Date
Customer Number
Customer Name
Ordered By
Purchase Order Number
Delivery Address
Street
City
State
Zip Code
Billing Address
Same as Delivery
P.O. Box or Street
City
State
Zip Code
Phone Number
Cell Number
Email address
Gate Combination

Payment Method:

Eel River Fuels Account

Please Bill My Eel River Fuels Account

Eel River Fuels Account Number
Account Name

Credit Card

Please Bill My Credit Card

Card Type	-- Select Card -- Visa MasterCard Discover Voyager
Expiration Date	-- Month -- January February March April May June July August September October November December -- Year -- 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Card Number
Authorization Number
Name on Card
Zip Code

Checking Account

Please Bill My Checking Account

Name on Account
Banking (Transit) Code
Bank Name
Routing Number
Checking Account Number
Click here to see check example

I Authorize Order to Eel River Fuels, Inc.

Products:

Fuel

List Product	Tank-Size	Quantity	Fill	Other Instructions	Ag Sales Tax Exempt	Propane Sales Tax Exempt
Clear Diesel
Dyed Diesel
Heating Oil #2
Regular Unleaded
Mid-Unleaded
Super Unleaded
Dyed Kerosene
Propane
Bio-Diesel B-20
Bio-Diesel B-99
Other

Hardware, Oil, and Grease

List Product	Container	Quantity	Fill	Other Instructions	Ag Sales Tax Exempt

Special Instructions