citizen action of new york | fuel group application

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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:

*How did you find out about us?

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)
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