ProGuard – Dealer Enrollment Application

Thank you for your interest in the ProGuard Oil Tank Protection Program.  In order to get started offering this important protection to your customers, please complete the enrollment application below.  After submission of your application, a representative will be in contact with you to explain in further detail how our program works.  Whenever possible we like to follow-up with a personal visit at a time convenient to you to introduce ourselves.  We look forward to speaking with you!

Company Name *
Contact Name *
Address *
City *
State *
Zip *
Telephone *
Fax
Email *
Web Address
Number of years in the fuel oil business *
Number of tanks applicable to the program *
Percentage of Will Call customers *
Number of gallons of heating oil distributed per year *
Estimated number of customer accidental fuel oil releases in the past 3 years: *
List state and national fuel oil dealer associations of which you are a member: *
List training programs servicemen and/or deliverymen are required to attend: *
List the names of each state in which you have fuel oil customers: *
Do you currently have or have you ever offered a tank protection program? *	Yes  No
If yes, name(s) of program(s) and number of customers enrolled:
How many covered releases and/or tank replacements from other program(s) to date? *
Do you know of any/suspected fuel oil releases, or any other facts or circumstances which may reasonably be expected to result in a customer or third party making a claim against you for damages due to a fuel oil release from a customer fuel oil system? *	Yes  No
If yes, please give details:
Have you or your company been the subject of any litigation, administrative or arbitration proceeding(s) or subject to any court or agency order or injunction as respects any cleanup and tank replacement programs similar to the ProGuard program? *	Yes  No
If yes, please provide details:
APPLICANT WARRANTY STATEMENT *	By checking this box, you represent that the above statements are true and that no material facts have been suppressed or misstated. Completion of this form does not automatically enroll you as an approved ProGuard provider. A representative from the ProGuard office will contact you within 5 business days regarding the status of your application for enrollment.
Electronic Signature *
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