Fuel Card Application

Gain control of your fleet today by completing the following application and benefit from online account management, security prompt controls and potential savings.

Short on time? Give us a call at 865-474-2953 to speak directly with a credit representative!

Accounts are available for commercial use only including diesel and mixed fuel fleets, but gas only fleets are not eligible for approval.

^*Required

People

Please include your officers and billing contact information below.

EFT Information

Autodraft is the required method of payment to establish a Fleet Account. Please include your EFT information below.

Fleet Information

Please include your fleet information below

Additional Information

Please include Driver ID and Truck Maintenance information below.

Review

Please review your information below

Sign

Please review the final form and sign

Company Information

Legal Name of Business* Physical Business Address* City* State* Zip Code*

I have a different mailing address

Phone* Example: (555)555-5555 Cell Phone Example: (555)555-5555 Fax Example: (555)555-5555 Email* * PFJ will use this email for any follow up communication Confirm Email* Tax Exempt?* Federal ID or BN #* Example: XX-XXXXXXX DOT # Dun & Bradstreet #

First Name* Last Name* Title*

Billing Contact

Same as Officer or Owner?

Billing Contact First Name Billing Contact Last Name Title Phone Example: (555)555-5555 Fax Example: (555)555-5555 Email

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Electronic Funds Transfer Information

Complete the below with your banking information to always stay up to date on invoice payments by using electronic auto-draft.

Bank Account #* Confirm Account #* Bank Name* Bank Routing #* Bank Address City* State* Zip Code* Contact First Name Contact Last Name Phone Example: (555)555-5555 Fax Example: (555)555-5555

Customer hereby agrees and acknowledges that: (1) Pilot may withdraw funds from the above-referenced bank account via electronic funds transfer at any time to collect on amounts due and owing Pilot; (2) a $75 processing fee will be debited to Customer’s 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; and (3) Pilot will be reimbursed, on demand, by bank wire for the gross amount of each invoice not paid by the electronic transfer of funds in addition to the processing fee described above. This authority is to remain in full force and effect until Pilot and the above-referenced Depository have received written notification from Customer of its termination in such time and in such manner as to afford Pilot and the above-referenced Depository a reasonable opportunity to act on it.

I agree to terms

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Fleet and Vehicle Information

Same as Officer or Owner?

Authorized Fleet Contact First name Authorized Fleet Contact Last name Title Phone Example: (555)555-5555 Cell Phone Example: (555)555-5555 Fax Example: (555)555-5555 Email Address Number of Vehicles* Number of Cards Requested* Expected Weekly Usage at Pilot and
Flying J (in Dollars $)*

Please select the types of fuel you will be buying with this card. * Check all that apply Commercial Diesel Gasoline Auto Diesel

Are you interested in any other fleet solutions? Check all that apply Freight Bill Factoring Truck Care Maintenance Packages

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Driver Id

This Driver ID will initially be applied to all of the cards that are requested. To ensure protection of the account, Customer must change the code for each individual card on the Fleet Card Website (www.pilotfleetcard.com) upon receipt of the cards.

Security Code*

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I have read and understand these terms and conditions.

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Fuel Card Application

People

EFT Information

Fleet Information

Additional Information

Review

Sign

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