Email Address: *
First Name: *
Last Name: *
Mailing Address: *
Apt/Suite
City: *
State: *
Select
AL
AK
AZ
CA
CO
CT
DC
DE
FL
GA
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:
Select
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(specify below)
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
2025
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