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Citizen action Fuel Group Application Yes! I would like to become a member of CAFG and save money this heating season. *First name: *Last Name: *Street/P.O. Box: *City: *State: *Zip: Delivery Address: (if different from mailing address entered above) Street/P.O. Box: City: State: Zip: *Area Code: *Number: *Email: *County of residence: BROOMECAYUGACHENANGOCOLUMBIA - Partial (call to verify)CORTLANDDELAWARE - Partial (call to verify)FULTONGENESEEHERKIMER - Partial (call to verify)LIVINGSTONMADISONMONTGOMERYONEIDAONONDAGAORLEANSOSWEGOOTSEGOSARATOGASCHENECTADYSUSQUEHANNA - Partial (call to verify)TIOGAWYOMING *How did you find out about us? unknown05 NewsletterYellow PagesWord Of MouthCanvassFuel DealerMailingsMisc.NewsletterNYSEGOffice of the AgingOnlinePennysaverPressStaffBinghamton CA Did a specific person refer you? If so, please provide their name here. Please provide directions to your location: My heating fuel is: Fuel Oil Kerosene Blend - fuel oil/kerosene Estimated annual fuel consumption in gallons: (Please enter numbers only, no letters.) Size of tank: Previous Fuel Dealer: Date of last delivery: *Location of fuel fill: Do you use oil to heat your hot water? Yes No My cooking fuel is: Propane Electric Natural Gas Other: *Choice of deliveries: Automatic * On-Call *Choice of payment: 30-day billing* Budget Plan* C.O.D. *Dealer may require credit application. Please call for details. Employment Information: (Required for 30-day billing or automatic delivery only) Employer's Name: Employer's Address: Employer's Phone: if you rent, landlord's name and address: Landlord's name: Landlord's address: I authorize Citizen Action to charge my credit card for: $25 Citizen Action membership fee $20 Citizen Action membership fee (Age 55 or over) $5 HEAP/Disability fee If you are joining as a HEAP or Disability member, please provide proof that you receive HEAP or Disability by fax or mail within 10 days for your membership to remain valid. Mailing Address: CAFG, 94 Central Avenue, Albany, NY 12206 or Fax: 518-465-2890. Participating Union/Military Personnel (Fee Varies) Select a Participating UnionAFGE -$5 One TimeAFSCME Local 1883 -$5 One TimeAFSCME Local 1912 -$5 One TimeATU Local 1145 -$5 One TimeATU Local 580 -$5 One TimeCarpenters Local 281 -$5 One TimeCarpenters Local 747 -$5 One TimeCSEA (Civil Servants Emp. Assoc.) -$5 One TimeCWA local 1126 -$5 One TimeCWA Local 14164 -$5 One TimeDisability -$5 One TimeGCIU local 898 -$5 One TimeIBEW local 325 -$5 One TimeIBEW Local 43 -$5 One TimeIBEW Local 83 -$5 One TimeIronworkers Local440 -$5 One TimeLaborer's Local 35 -$5 One TimeLaborers Local 7 -$5 One TimeMachinists Local 2001 -$5 One TimeMilitary -$5 One TimeMill Wrights local 1163 -$5 One TimeNEA (National Education Assoc.) -No FeeNew HartfordEmployees Union -$5 One TimeNYSCOPBA -$5 One TimeOMCE -$5 One TimePASS -$5 One TimePEF (Public Employee Federation) -No FeePlumbers and Pipefitters 112 -$5 One TimeSEIU -$5 One TimeTeamster Local 693 -$5 One TimeTeamsters Local 182 -$5 One TimeUAW Local 2243 (United Auto.,Aero.,Agric. Workers) -$5 One TimeUAW Local 2367 (United Auto.,Aero.,Agric. Workers) -$5 One TimeUFCW (United Food&Commercial) -$5 One TimeUnited Transportation Union -$5 One TimeUPSEU (United Public Svc. Emp. Union) -$5 One TimeUSW Local 4831 -$5 One TimeUtica Fire Fighters -$5 One TimeUTU Local 318 -$5 One Time If you are joining as a union member please select a participating union and provide proof of union membership by fax or mail within 10 days for your membership to remain valid. Mailing Address: CAFG, 94 Central Avenue, Albany, NY 12206 or Fax: 518-465-2890. Would you like us to automatically renew your membership and charge your credit card each year? Yes No Yes, please send me information about Citizen Action of New York! Learn more about how we're fighting for racial, economic, social and environmental justice. Please contact us with any questions: Citizen Action Fuel Group 94 Central Avenue, Albany, NY 12206 1-800-559-4645 (800-559-4OIL) Email: cafg@citizenactionny.org
Yes! I would like to become a member of CAFG and save money this heating season.
*First name:
*Last Name:
*Street/P.O. Box:
*City: *State: *Zip:
Delivery Address: (if different from mailing address entered above)
Street/P.O. Box:
City: State: Zip:
*Area Code: *Number:
*Email:
*County of residence: BROOMECAYUGACHENANGOCOLUMBIA - Partial (call to verify)CORTLANDDELAWARE - Partial (call to verify)FULTONGENESEEHERKIMER - Partial (call to verify)LIVINGSTONMADISONMONTGOMERYONEIDAONONDAGAORLEANSOSWEGOOTSEGOSARATOGASCHENECTADYSUSQUEHANNA - Partial (call to verify)TIOGAWYOMING
*How did you find out about us? unknown05 NewsletterYellow PagesWord Of MouthCanvassFuel DealerMailingsMisc.NewsletterNYSEGOffice of the AgingOnlinePennysaverPressStaffBinghamton CA
Did a specific person refer you? If so, please provide their name here.
Please provide directions to your location:
My heating fuel is: Fuel Oil Kerosene Blend - fuel oil/kerosene
Estimated annual fuel consumption in gallons: (Please enter numbers only, no letters.)
Size of tank:
Previous Fuel Dealer:
Date of last delivery:
*Location of fuel fill:
Do you use oil to heat your hot water? Yes No
My cooking fuel is: Propane Electric Natural Gas Other:
*Choice of deliveries: Automatic * On-Call
*Choice of payment: 30-day billing* Budget Plan* C.O.D. *Dealer may require credit application. Please call for details.
Employment Information: (Required for 30-day billing or automatic delivery only)
Employer's Name:
Employer's Address:
Employer's Phone:
if you rent, landlord's name and address:
Landlord's name:
Landlord's address:
I authorize Citizen Action to charge my credit card for:
$25 Citizen Action membership fee
$20 Citizen Action membership fee (Age 55 or over)
$5 HEAP/Disability fee If you are joining as a HEAP or Disability member, please provide proof that you receive HEAP or Disability by fax or mail within 10 days for your membership to remain valid. Mailing Address: CAFG, 94 Central Avenue, Albany, NY 12206 or Fax: 518-465-2890.
Participating Union/Military Personnel (Fee Varies) Select a Participating UnionAFGE -$5 One TimeAFSCME Local 1883 -$5 One TimeAFSCME Local 1912 -$5 One TimeATU Local 1145 -$5 One TimeATU Local 580 -$5 One TimeCarpenters Local 281 -$5 One TimeCarpenters Local 747 -$5 One TimeCSEA (Civil Servants Emp. Assoc.) -$5 One TimeCWA local 1126 -$5 One TimeCWA Local 14164 -$5 One TimeDisability -$5 One TimeGCIU local 898 -$5 One TimeIBEW local 325 -$5 One TimeIBEW Local 43 -$5 One TimeIBEW Local 83 -$5 One TimeIronworkers Local440 -$5 One TimeLaborer's Local 35 -$5 One TimeLaborers Local 7 -$5 One TimeMachinists Local 2001 -$5 One TimeMilitary -$5 One TimeMill Wrights local 1163 -$5 One TimeNEA (National Education Assoc.) -No FeeNew HartfordEmployees Union -$5 One TimeNYSCOPBA -$5 One TimeOMCE -$5 One TimePASS -$5 One TimePEF (Public Employee Federation) -No FeePlumbers and Pipefitters 112 -$5 One TimeSEIU -$5 One TimeTeamster Local 693 -$5 One TimeTeamsters Local 182 -$5 One TimeUAW Local 2243 (United Auto.,Aero.,Agric. Workers) -$5 One TimeUAW Local 2367 (United Auto.,Aero.,Agric. Workers) -$5 One TimeUFCW (United Food&Commercial) -$5 One TimeUnited Transportation Union -$5 One TimeUPSEU (United Public Svc. Emp. Union) -$5 One TimeUSW Local 4831 -$5 One TimeUtica Fire Fighters -$5 One TimeUTU Local 318 -$5 One Time If you are joining as a union member please select a participating union and provide proof of union membership by fax or mail within 10 days for your membership to remain valid. Mailing Address: CAFG, 94 Central Avenue, Albany, NY 12206 or Fax: 518-465-2890.
Would you like us to automatically renew your membership and charge your credit card each year? Yes No
Yes, please send me information about Citizen Action of New York! Learn more about how we're fighting for racial, economic, social and environmental justice.
Please contact us with any questions: Citizen Action Fuel Group 94 Central Avenue, Albany, NY 12206 1-800-559-4645 (800-559-4OIL) Email: cafg@citizenactionny.org