GENERAL INFORMATION
 Legal Name of Business  Trade Name of Business
 Business Street Address
 City State   Zip Phone Number
 Cell Number*  Fax Number  Email Address

 PROPRIETOR, PARTNERS OR CORPORATE OFFICERS (Please provide an alternate address where we may reach you.)
 Name  1.  2.
 Title          
 Street          
 City, State, Zip          
 Home Phone          
 Email          
 Social Security #          
Authorized to make account changes ?
Yes No
Yes No
Social Security Number required in order to carry out security-related duties for the company. Home phone or cell phone number will be called in case of emergency. By signing this credit application, I authorize the person(s) listed on the credit application to carry out security related duties for the company. 		 
Please select your products & services.
Fuel Card Bridgestone/Firestone
PlusChek™ Internet Load Matching
ATM/Debit Internet Load Matching
      & CREDITSTOP
Permits Roadside Assistance
  Other:
 
Send me more information on: 		 
Factoring Permits
TripPak OVERNIGHT
 DESCRIPTION OF BUSINESS Corporation Partnership Proprietorship  Federal ID#
 Incorporation Date  If subsidiary, name parent company
 BANK & TRADE INFORMATION  Bank Name  Acct#  
 Contact  Phone
 City  State  Zip  Fax     
  Fuel References Preferred
 REFERENCE #1  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 REFERENCE #2  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 REFERENCE #3  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 CREDIT INFORMATION  Financial Statement Provided**
Yes No
Required if credit line requested
is more than $10,000
 Credit Line Requested Dun & Bradstreet #
 #Tractors #Trailers #Cards
 PAYMENT METHOD  Required information for all payment methods:
  1. AutoPay (ACH)***
  2. Internet Pay
  3. Faxed Electronic Check
  4. Other
 Bank Name:  Bank Phone:
 ABA/Routing #  Account Number:
 Day(s) of the week for Payment to Fleet One (select as many as you like)
Monday Tuesday Wednesday Thursday Friday
 *** If it is a weekly ACH debit to your account, the debit will be made for the  previous7 days of purchase activity.
*Any financial statement submitted with this application will facilitate the establishment of your account and will be relied upon by Fleet One. Any such statements will be kept strictly confidential.

Permission is herewith granted to obtain credit information from all listed references, including my bank. All financial information submitted in support of this new Account and credit application is true and complete in all respects. My account is subject to a late charge of 1.5% per month (18% per annum) on all past due invoices. Furthermore, I understand that my Cards may be turned off if my account is past due and that any collection fees (including attorney fees) incurred by Fleet One, which the parties hereby fix at 33 1/3% of any balance due plus court costs, will be borne by my account.By signing this credit application and using services of Fleet One, I certify that I am authorized to make this request on behalf of this company, and it is agreed that all purchases will be paid in accordance with the terms & conditions. I assume personal and individual responsibility and liability, and guarantee payment of all charges due and payable to Fleet One by the company or corporation listed herein. I hereby consent and authorize the use of my consumer credit report in the credit evaluation process.
SIGNATURE OF PROPRIETOR, PARTNER OR CORPORATE OFFICER________________________________________________________
PRINT NAME_________________________________________________________________DATE_______________________________
SIGNATURE OF WITNESS__________________________________________________________________________________________
PRINT NAME_________________________________________________________________DATE_______________________________


Terms and Conditions

I have read and agree to the terms and conditions