Fuel Order Form

1-800-522-6287

Fax: 414-359-9576

www.quickfuel.com
Fuel Order Form
Company
If you have an existing Quick Fuel account, please enter your account number
Primary Contact*

First NameLast Name
Primary Contact Phone Number*

Area CodePhone Number
Primary Contact E-mail*
Site Contact*

First NameLast Name
Site Contact Phone Number*

Area CodePhone Number
Site Contact E-mail*
E-Ticket Recipient*

First NameLast Name
This recipient will receive a copy of the delivery ticket via email after your fuel delivery is complete.
E-ticket Recipient Phone Number*

Area CodePhone Number
E-ticket Recipient E-mail*
Location to be fueled

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this a job site?

YesNo
If an exact address is not available, please provide directions, cross roads, etc.
PO or Job #
Delivery Date/Time
Start Date*

MonthDayYear
End Date*

MonthDayYear
Start Time*

:HourMinutesAM/PM Option
End Time*

:HourMinutesAM/PM Option
What will need to be fueled?
Type:

EquipmentGeneratorReeferVehicles
Product
Product
Product
Product
Est. Total Gallons
Est. Total Gallons
Est. Total Gallons
Est. Total Gallons
To add more lines to the chart below, click the "Save and Add Row" button to the right.
Additional Information/Special Instructions
Should be Empty: