Mastercard Corporate Fleet Card Page 2
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1
2
3The RaceTrac MasterCard Corporate Fleet Card®
Account Application
Company Name
Business Est.
Contact Person
Present Owner Since
Mailing Address
E-mail Address
City
State
Zip Code
Phone
Extension
_
(
)
Business Information
Number of
Number of Vehicles
Number of Drivers
Annual Company Revenue
Amount of Credit Requested
Cards Required
$
c $0 to $500
c $501 to $1000
Federal ID#
Net Worth
$
c $1001 to $2500
c $2501 and over
Financial References
Bank
Years at Bank
Method of Payment
c Wire
c EFT
Contact Person
c Check
c Other________
Mailing Address
Checking Account #
City
State
Zip Code
Phone
Extension
_
(
)
Form of Ownership (You Must Complete One)
Partnership or Sole Proprietorship
c Corporation
c Partnership
c Sole Proprietorship
Principal Owner 1
Principal Owner 2
/
/
/
/
Corporation
Social Security Number
Social Security Number
President
Home Address
Home Address
Controller
City
State
Zip Code
City
State
Zip Code
(
)
(
)
Incorporated In (year)
Home Phone
Home Phone
State of
Please complete both sets of required information below
The RaceTrac MasterCard Corporate Fleet Card is a program of Comdata Network, Inc. ("Comdata"). It is understood that Comdata reserves the right to verify all credit information. If
required, Applicant agrees to furnish additional financial information. ALL INFORMATION IS KEPT CONFIDENTIAL. This Application does not entitle Applicant to any right or services
with Comdata or RaceTrac, including the extension of credit. All decisions on the extension of credit are within the sole discretion of Comdata. RaceTrac® is a registered service mark of
RaceTrac Petroleum, Inc., which is not affiliated in any way with Comdata. Applicant understands and agrees that RaceTrac Petroleum, Inc. has no obligation of any kind whatsoever to
Applicant arising from or in any way related to this Application or any information provided by Applicant.
Applicant hereby authorizes above referenced Financial References to release all history and releases them from any liability for use of information received by Comdata.
By signing below, Applicant acknowledges and agrees to the RaceTrac MasterCard Corporate Fleet Card Agreement attached to this Application.
/
/
X
,
Signature
Name (Printed)
Title
Date
As an owner of the Applicant, I recognize that my individual credit history may be a factor in the evaluation of the credit history of Applicant, and I hereby consent to and authorize the
use of my consumer credit report by Comdata from time to time as needed in the credit evaluation process.
/
/
X
Signature
Name (Printed)
Date
Would you like to receive promotional offers via e-mail from RaceTrac and other program participants?
c Yes, I would like to receive promotional offers.
c No, I would not like to receive promotional offers.
If this Application is approved by Comdata, a specific credit limit will be assigned based upon Applicant's credit report or the credit report(s) of Applicant's owner(s).
You can fax this application to (615) 376-6960, Attention: Credit Department
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