Pilot Flying J Fleet Fuel Card Program
COMPANY INFORMATION (REQUIRED)
LEGAL NAME
OF BUSINESS
PHONE
CELL PHONE
FAX
PHYSICAL
BUSINESS
ADDRESS
MAILING
ADDRESS
or PO BOX
INCORPORATION
DATE
EMAIL
DESCRIPTION
OF BUSINESS
DUN &
BRADSTREET #
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
DOT#
TAX EXEMPT? (circle one)
YES
NO
TYPE OF BUSINESS (circle one)
FEDERAL
ID #
PROPRIETORSHIP
CORPORATION
PARTNERSHIP/LLC
PROPRIETOR, PARTNERS OR CORPORATE OFFICERS (REQUIRED)
1. NAME
1. TITLE
1. SOCIAL SECURITY #
2. NAME
2. TITLE
2. SOCIAL SECURITY #
BILLING INFORMATION
(CHECK PREFFERED METHOD(S) OF STATEMENT DELIVERY)
CONTACT
NAME
TITLE
PHONE
FAX
EMAIL ADDRESS
ELECTRONIC FUNDS TRANSFER (EFT) INFORMATION (REQUIRED)
I (we) hereby authorize Pilot Travel Centers, LLC, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account indicated below and the depository named below, hereinafter called BANK, to debit the same to such account. We further agree to the terms and
conditions set forth below for the electronic transfer of funds. 1- A $25 processing fee will be debited to our accounts receivable for each transfer returned to Pilot for non-sufficient funds, or for any other reason which would cause the funds to be unavailable for drawing by Pilot. 2-Pilot
will be reimbursed by certified check for the Gross Amount of each invoice not paid by the electronic transfer of funds in addition to the processing fee described in (1) above. 3-Pilot reserves the right to withdraw the Electronic Funds Transfer Program at any time. The authority is to
remain in full force and effect until COMPANY and BANK has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
BANK NAME
BANK ACCOUNT #
BANK ROUTING #
BANK ADDRESS
CITY
CONTACT
NAME
STATE
PHONE
FAX
TITLE
FAX
ZIP CODE
FLEET AND VEHICLE INFORMATION (REQUIRED)
AUTHORIZED
FLEET CONTACT
PHONE
CELL PHONE
NUMBER OF
VEHICLES
# OF CARDS
REQUESTED
EMAIL ADDRESS
EXPECTED WEEKLY
USAGE AT PILOT AND
FLYING J (IN DOLLARS $)
PRODUCTS REQUESTED
(circle all that apply)
GASOLINE
DIESEL
SCALES
PROPANE
ADDITIVES
DEF
OTHER
DRIVER IDs (Numbers Only, e.g. 1234) (REQUIRED)
CARD 001:
CARD 004:
CARD 007:
CARD 010:
CARD 002:
CARD 005:
CARD 008:
CARD 011:
CARD 003:
CARD 006:
CARD 009:
CARD 012:
If additional cards are requested, please complete on a
separate form and include with application
I CERTIFY THAT I AM AUTHORIZED TO MAKE THIS REQUEST ON BEHALF OF THIS COMPANY AND FULLY AGREE TO THE TERMS AND CONDITIONS SET FORTH HEREIN
SIGNATURE OF
OFFICER LISTED ABOVE:
DATE:
PRINT NAME:
TITLE:
In accepting the card(s) by signing, using or permitting use by others, the undersigned agrees to the Terms and Conditions as contained on and in the folder in which undersigned receives the card(s) and as on Pilot’s
website, and, accordingly, to pay Pilot Travel Centers LLC for purchases made and credit extended with the use of the card(s). It is understood such Terms and Conditions provide, among other things, finance charges
not in excess of those permitted by law to be charged. In the event it becomes necessary for us to incur collection costs, or institute suit to collect any amount due under this agreementor any portion thereof, your
company agrees to pay such additional collection costs, charges, and expenses, including reasonable attorney’s fees incurred by our company. The undersigned authorizes Pilot Travel Centers LLC to obtain a credit
report on applicant, its officers, and partners, and contact references, and provide a copy of this application to those references as deemed necessary by Pilot. Customer waives any dispute claims to its invoice if
Customer fails to notify Pilot, in writing, within 60 days of the invoice date. Customer agrees that Pilot Travel Centers LLC may exchange information relating to you and/or company and may distribute such credit
information to third parties.
SUBMIT YOUR APPLICATION VIA EMAIL OR FAX AT:
FOR MORE INFORMATION PLEASE VISIT OR CALL:
[email protected]
www.pilotflyingj.com
or
FAX: 865-297-9602
or
PH 855-478-7587