Dysart's Fleet Card Program

Business Name*

First Last

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address (if different from mailing)

Street Address Address Line 2 City State ZIP Code

Business Phone*

SSN#*

Social Security Number

Business Fax*

Business Email

Type of Business*

Corporation
Partnership
Sole Proprietorship

Federal ID #

Name of Officer/Partner/Owner(s)*

First Last Title

Name of Officer/Partner/Owner(s)

First Last Title

Name of Officer/Partner/Owner(s)

First Last Title

Years in Business*

Number of Employees*

Name of Accounts Payable*

Purchase Order Numbers Required*

Yes
No

Bank Reference*

Bank Address*

Street Address Address Line 2 City State ZIP Code

Checking Account Number*

Loan Account Number(s)*

Person to Contact*

First Last

Trade Reference Contact 1*

First Last

Trade Reference Address 1*

Street Address Address Line 2 City State ZIP Code

Trade Reference Phone 1*

Trade Reference Email 1

Trade Reference Contact 2*

First Last

Trade Reference Address 2*

Street Address Address Line 2 City State ZIP Code

Trade Reference Phone 2*

Trade Reference Email 2

Trade Reference Contact 3*

First Last

Trade Reference Address 3*

Street Address Address Line 2 City State ZIP Code

Trade Reference Phone 3*

Trade Reference Email 3

Trade Reference Contact 4*

First Last

Trade Reference Address 4*

Street Address Address Line 2 City State ZIP Code

Trade Reference Phone 4*

Trade Reference Email 4

For heating oil accounts, please provide directions to your business and a description of the property?

Credit Terms

Station/Shop: Full payment within 15 days of statement date
Kard Gard/Fleet Fuel: Full payment within 7 days of invoice date
Wholesale: 1% discount within 10 days or full payment on the 11th day
Lubricants: Full payment within 30 days from statement date
Home Heat: Full payment within 10 days of invoice date
Dysart’s Credit Card: Full payment within 30 days of statement date

Please select one below to choose desired account type and to acknowledge terms.

Agreement

I/We fully understand the credit terms and agree to the proper payment in consideration of extended credit and that all information on this form is true and correct. I/We agree that the bank and references are provided to allow Dysart’s Service to contact them to use in its credit decision and that Dysart’s Service may request further credit information from a credit reporting agency.
In the event that our account becomes delinquent, I/We agree to pay all finance charges assessed at 1.5% (one point five percent) per month (eighteen percent per Annum) on any unpaid balance over 30 days. I/We also agree to pay all collection costs and legal fees should our account be presented for collection with an authorized agency or attorney.
I/We do hereby personally, jointly and severally, guarantee payment of this account at all times.

Signature*

Name Title

Signature

Name Title

Signature

Name Title

Opt-In*

I agree to the privacy policy of Dysart’s.

Dysart’s Fleet Card Program

Dysart’s Fleet Card Application

Agreement