Propane Online Order & Quote Form

Propane Order Form

Must have a chargeable account with Countryside to order propane online

*Required fields

Contact Info

*Name on Account:

Account Number:

Must be numeric

*Phone:

*Email:

Billing Address

*Billing Street:

*Billing City:

*Billing State:

Tank Location Address

*Same As Billing:

No
Yes

Tank Street:

Tank City:

Tank State:

Tank Zip:

*Please select a location near you:

Request a Refill on Any of the Following

*Request Type:

Propane
Fuel Oil for Home Heating
Fuel

Tank Percentage:

Estimate of Gallons Requested:

Propane Comments:

Fuel Oil Inches in Tank:

Estimate of Fuel Oil Gallons Requested:

Fuel Oil Comments:

Fuel Inches in Tank:

Type of Fuel:

Gasoline - 87 with Ethanol
Gasoline - 87 without Ethanol
Gasoline - 91 Premium
Off-Road Diesel
On-Road Diesel

Gallons of Fuel Requested:

Fuel Comments:

Security code:

Countryside Cooperative

PO Box 250
514 East Main Street
Durand, WI 54736

Phone:
715-672-8947
Toll-free:
800-236-7585
Fax:
715-672-5131

Propane Quote Request

*Required fields

*Name:

*Phone:

*Email:

*Street Address:

*City:

*State:

*Zip:

*Are you a current customer?:

No
Yes

Type of Account:

Residential
Farm
Commercial

*Please select a location near you:

*Product(s) for which you need a quote:

Fuel Market Price
Fuel Oil Market Price
Other/Commercial Requests
TrueComfort+ Price
New Customer Installation Price
Pre-Buy Price
Propane Market Price
Fixed Price

If Other/Commercial, please list more details:

Security code:

Countryside Cooperative

PO Box 250
514 East Main Street
Durand, WI 54736

Phone:
715-672-8947
Toll-free:
800-236-7585
Fax:
715-672-5131