Welcome NTA Customer to the Pilot Flying J Fleet 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.

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* 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 Incorporation Date*

Email* * PFJ will use this email for any follow up communication Confirm Email* Description of Business Tax Exempt?* Federal ID or BN #* Example: XX-XXXXXXX DOT # Dun & Bradstreet # Country(ies) of Operation* Type of Business*

First Name* Last Name* Title*

+ Add Another Officer or Owner 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

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 $50 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 $)*

Products Requested

Other Gasoline Diesel Propane DEF Scales Additives

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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*

Truck Maintenance

Check "yes" & complete if interested in Pilot Flying J Truck Care Services, or check "no" if not interested at this time.**

Yes No

** Please check here and complete the requested information below if you are interested in applying for additional credit and direct billing for services and products offered by PTC through its Pilot Flying J Truck Care shops and its Pilot Flying J Truck Care Emergency Road Service. If approved, separate credit terms and payment terms may be extended regarding these services and products. You will be invoiced separately for these products and services.

Truck Maintenance Contact First Name

Truck Maintenance Contact Last Name

Phone Number Example: (555)555-5555

Email * PFJ Will Use This Email For Any Follow Up Communication

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I have read and understand these terms and conditions.

Previous Submit

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Welcome NTA Customer to the Pilot Flying J Fleet Card Application

People

EFT Information

Fleet Information

Additional Information

Review

Sign

Sign up and gain access to all Pilot and Flying J fuel prices

The Benefits

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