New Customer Inquiry Form

Please fill out the form below, or click here to download a printable form.

  • - State -
  • AL
  • AK
  • AZ
  • AR
  • CA
  • CO
  • CT
  • DE
  • FL
  • GA
  • HI
  • ID
  • IL
  • IN
  • IA
  • KS
  • KY
  • LA
  • ME
  • MD
  • MA
  • MI
  • MN
  • MS
  • MO
  • MT
  • NE
  • NV
  • NH
  • NJ
  • NM
  • NY
  • NC
  • ND
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VT
  • VA
  • WA
  • WV
  • WI
  • WY
  • - Current Tank Size -
  • 120g
  • 250g
  • 325g
  • 500g
  • 1000g
  • Do Not Know
  • - How Many Gallons Used per Year -
  • 0-500g
  • 501-1000g
  • 1001-1500g
  • 1500g+
  • Do Not Know
  • - Tank Owned or Rented -
  • Owned
  • Rented
  • Do Not Know
  • - How did you hear about us? -
  • Internet
  • Neighbor/Friend
  • Flyer
  • Saw a Polar Gas truck
  • Other
Submit