Auto Pay - Formstack

Auto Pay Sign-up

When you sign up for Auto Pay we will automatically charge the credit card you provide us whenever a service call or delivery is made. All service invoices and delivery invoices will be e-mailed as well.

Name*

First Name

Last Name

Email*

Phone*

Account Information

Patterson Fuels Account Number

Billing Address

Credit Card Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Shipping Address

Delivery Address

Address Line 1

Address Line 2

City

State

ZIP Code

Payment

Credit Card*

Form secured by Formstack

Powered by Formstack Create your own form ›