Email Address: *
First Name: *
Last Name: *
Mailing Address: *
Apt/Suite
City: *
State: *
AL
AK
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
VA
VI
VT
WA
WI
WV
WY
Zip Code/Postal Code: *
Please check the appliances that you fuel with Blue Rhino:
Gas Grill
Gas Griddle
Gas Smoker
Fire Pit/ Fire Table
Patio Heater
Other Heater
How often do you buy propane for the above propane appliances, on average?
Monthly
Quarterly
Once a Year
Twice a year
Other
How many standard propane grill tanks do you own?
1
2
3
4
5
6+
Name of the store where you usually buy your tank:
7-Eleven
Ace Hardware
Albertson's
Circle K
CVS
Dollar General
Family Dollar
Food Lion
Giant
Giant Eagle
Hannaford
HEB
Home Depot
Kroger
Lowe's Food
Lowe's
Menards
Publix
Rite-Aid
Safeway
Speedway
Stop & Shop
Supervalu
Walgreens
Wal-Mart
Winn-Dixie/Bi-Lo
Other
Date of last propane purchase (if known):
MM
01
02
03
04
05
06
07
08
09
10
11
12
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2020
2021
2022
2023
2024
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