Customer Information
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Equity Account ID
*
Found in the upper right hand corner of statements and invoices.
Daytime Phone Number
*
Please enter a valid phone number.
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Email Address
*
example@example.com
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The Equity Energy Service Information
Energy Service Location
*
Please Select
Effingham
Farina
Lovington
Marshall
West Liberty
Unknown
Energy Sales & Service Technician
*
Please Select
Kevin Shelton - Farina Region
Ted Miller - Lovington Region
Chris Ferguson - West Liberty Region
Chris Green - Marshall Region
Mac Hingson - Effingham Region
Jared Probst - Effingham Region
Unknown Driver
Please note: Cash accounts will not be accepted.
Submit
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