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Name
*
First
Last
Physical Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
*
Are you a VFS Account Holder?
*
Yes
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Owned or Leased Tank?
*
Owned
Leased
Tank Size
*
Current % in Tank
*
Requested Delivery Amount
*
Fill
200 gal
150 gal (Minimum Delivery)
Preferred Method of Payment
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Charge to Account
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C.O.D.
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