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The undersigned applicant/buyer ("Applicant") represents that the
information given in this application is complete and accurate and authorizes
Card Issuer to check with credit reporting agencies, credit references and other sources
disclosed to confirm information given; 2) Applicant requests a business
charge account, if approved for credit, and one or more business charge cards from
the card issuer, which is Zarco 66 Inc ("Card Issuer"); 3) Applicant agrees to
the terms and conditions set forth in the Business Charge Account Agreement
provided with this application and/or provided with the business charge card(s). Use of any card issued pursuant to this
application confirms Applicant's agreement to said terms and conditions; 4)
If this Account is for a partnership or a proprietorship, a partner or principal
must sign this application and the undersigned's personal credit will be used
in making a credit decision and they hereby authorize Card Issuer to
obtain a consumer report. In the event that this application is denied based
upon information contained in a consumer credit report of the undersigned, they authorize the Card Issuer to report the reason for the denial to the Applicant. Direct inquiries
of businesses where the undersigned maintains accounts may also be made; 5) Applicant
agrees that in the event the account is not paid as agreed, Card Issuer may
report the undersigned's liability for and the status of the account to
credit bureaus and others who may lawfully receive such information. |
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Full Legal Company Name of
Applicant/Buyer
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Phone #
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Fax#
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Write
company name as you wish it to appear on cards. Limit of 20 characters
'including spaces. Unless specified, no company name will appear on cards.
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DBA or AKA
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Subsidiary of
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Applicant's
Taxpayer ID # (TIN, FEIN or SSN)
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Headquarters Name, Physical
Address and Phone # (Do not include PO Box)
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SIC
Code or Type of Business
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Billing Contact
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Billing Address
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City
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State
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Zip+4
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Principal(s)/Authorized
Officer(s)
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Title(s)
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In Business Since
(yyyy) |
Year of Incorporation (yyyy)
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Fiscal
Year Start (mm)
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Avg Monthly Fuel Expenditures |
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Number
of Vehicles
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Check
payment preference (payment terms subject to credit approval):
Weekly Direct Debit
Bi-Weekly Direct Debit Monthly Direct Debit
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| IMPORTANT:
If your estimated monthly vehicle expenditures equal $1,500 or more, please
attach your most recent annual and current financial statements. |
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Complete
this Section Accurately. Select One:
Corporation Partnership Proprietorship PC or PA LLC
Is this account for a company that has been incorporated less than three
years, a partnership, a proprietorship, a professional corporation |
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association, or a limited liability company? El No Dyes (If YES, complete and attach the Personal Guaranty on page 2.) |
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Primary Business Bank
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Address
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City
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State
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Zip+4
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Bank Contact Person
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Phone #
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Commercial
Account No.
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Designate
the person authorized to receive all charge cards, reports, and other such
information we provide from time to time and to take
actions
with respect to your account and
account access. This is also the person designated
by your company to provide all fleet vehicle,
driver and other
information we may request. |
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Authorized Contact Name
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Title
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Phone #
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Fax #
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Mailing Address (if different
from billing address)
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City
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State
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Zip+4
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Email
address
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Check here if business is exempt from motor fuels tax (Attach
tax exempt certificate) |
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| INFORMATION
SHARING CLAUSE: Card Issuer or its affiliates may, to the extent allowed by
law, share all information disclosed or generated through this application. |
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| AUTHORIZED SIGNATURE REQUIRED |
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Any
person signing on behalf of a business attests that the Applicant is a valid business entity, that, if applicable, the execution of this application has been duly
authorized by all necessary action of Applicant's governing
body, and that the undersigned is authorized to make this application on
Applicant's behalf. |
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Signature
X |
Date
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Print
Name
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Title
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Complete the Personal Guaranty below if this account is for a: |
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·Company that has been incorporated less than three
years |
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·Partnership |
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·Proprietorship |
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·Professional corporation or association |
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·Limited liability company |
| PERSONAL
GUARANTY (SEE ABOVE) |
| In
consideration of Card Issuer financing purchases under the Business Charge
Account Agreement (as the same may hereafter be modified, extended or
amended, "the Agreement"), the undersigned guarantor
("Guarantor") hereby agrees to unconditionally personally guarantee
payment and performance under
any account established pursuant to this application, of any obligation of
Applicant to Card Issuer or any assignee of Card Issuer, in the event the
above
Applicant fails to do so. This is a guaranty of payment and not
merely of collection. Guarantor agrees to pay, upon demand, any amount owed
by Applicant to
Card Issuer and due under the Agreement. Card Issuer shall not be required
to initiate any action against, nor exhaust any remedies with respect to
Applicant
or any other guarantor prior to making demand upon Guarantor. Guarantor
hereby waives any notices regarding Applicant's account or this guaranty
and
agrees that this guaranty shall be applicable until the Agreement
has terminated and all amounts due have been paid in full. Guarantor agrees
that in the
event the account is not paid as agreed, Card Issuer may report Guarantor's
liability for and the status of the account to credit bureaus and others who
may
lawfully receive such information. Guarantor hereby agrees that Card Issuer
may extend the time for payment and release any other security for the
agreement
without affecting in any way the obligations of Guarantor. Guarantor
waives any and all suretyship defenses. Personal credit of Guarantor will be
used in
making a credit decision and Guarantor hereby authorizes Card Issuer to
obtain a consumer credit report of Guarantor. Direct inquiries of businesses
where
the undersigned maintains accounts may also be made. In the event this
application is denied based upon information in a consumer credit report
of
Guarantor, Guarantor authorizes the Card Issuer to report the reason for the
denial to Applicant. |
Guarantor's Signature
X |
Print Name
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Social Security No.
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Date of Birth
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Guarantor's Residential Address
- street, city, state, zip (Do not include PO Box)
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Phone #
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Date
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| FOR
OFFICE USE ONLY |
| Opportunity Number |
Sales Code |
Plastic Type |
Coupon Code |
Account Number |
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