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Order Fuel

Please provide the following information to place your fuel order:

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Account Number (if known)
 Amount to be Ordered (in gallons)*
 
Date requested for delivery:
 Type of Fuel:*
 
 
First Name*
  		Last Name*
 
Address*
  		Address 2
City*
 		 State*
 
Zip Code*
   		 County
Home Phone (10 digits)*
   		 Cell Phone
Work Phone
 		 Email Address*
   
   


 
 

Capitol Di$count Fuel © 2010, All Rights Reserved
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9600 Colonial Ave, Fairfax, VA 22031 | Billing: 115 E. Main St., Purcellville, VA 20132
(703) 978-6400 | Fax (540) 338-6401