Furnace Rental Online Application Form

Bosanac Heating & Electric offers Furnace Rental for its customers at the convenience of low monthly payments.

RENTAL benefits:

• Low, affordable monthly rates
• No up-front equipment costs
• No repair bills - just worry-free home comfort
• Free equipment replacement during contract term - should your equipment be un-repairable as a result of normal use
• Service provided by responsive, local service providers
• Rate Increase Protection - Your Vista contract will not be subject to arbitrary, unexpected, and excessive rate increases. The contract includes a rate increase guarantee.
• The convenience of payment on your local gas utility bill (where available) or by pre-authorized payment

Required fields are marked with *

FIRST NAME * LAST NAME * DATE OF BIRTH * day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 month January February March April May June July August September October November December year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

STREET # * STREET NAME * UNIT CITY / TOWN * POSTAL CODE *

PHONE * PHONE (alt.) E-MAIL *

* I AM THE HOMEOWNER    I AM A TENANT    RENTAL PROPERY THAT I OWN

NEW EQUIPMENT * NEW EQUIPMENT TYPE(S) + Electric Water Heater Conventional Gas Water Heater (no fan) Power Vent Water Heater (with fan) Tankless Water Heater Furnace Air Conditioner HVAC System (Furnace & A/C) Other (describe in note) PREFERRED INSTALL DATE & TIME day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 month January February March April May June July August September October November December no preference MORNING AFTERNOON EVENING * IS THIS A COMMERCIAL APPLICATION? Yes    No (i.e. restaurant, office, retail store...) OLD EQUIPMENT CURRENT RENTAL PROVIDER -- Reliance National Home Services Other Rental Company None (Owned Equipment) OLD EQUIPMENT TYPE(S) + Electric Water Heater Conventional Gas Water Heater (no fan) Power Vent Water Heater (with fan) Tankless Water Heater Furnace Air Conditioner HVAC System (Furnace & A/C) Other (describe in note) None (new install, no replacement) OLD RENTAL RATE  $  * DID YOU SIGN AN AGREEMENT WITH YOUR OLD RENTAL EQUIPMENT PROVIDER? Yes    No + Use CTRL key to select more than one equipment type. COMMENTS and NOTES *  You authorize Bosanac Heating & Electric to make any inquiries concerning your credit and you authorize any consumer reporting agency, or any other company with whom you have financial relations to furnish credit information to Bosanac Heating & Electric. Enter Code *: [ Different Image ]