Would you prefer to print, complete, and then scan? Click here.AGREEMENT TO DO BUSINESS ELECTRONICALLYUntitled(Required) I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound by this agreement. I further agree that my signature on this document is as valid as if I had signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I choose to sign electronically. Under penalty of perjury, I hereby affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and I am legally bound by these terms and conditions. BUSINESS CREDIT INFORMATIONFull Legal Name(Required)Federal ID # or Social Security #(Required)Billing Address(Required)City(Required)State(Required)Zip(Required)Phone Number(Required)Fax NumberBilling Contact Name(Required)Email Address(Required) Physical AddressCityStateZipPlease Check One:(Required) Corporation Partnership Proprietorship Other OtherPrincipal Business Activity(Required)In Business Since(Required)BUSINESS BANK & TRADE REFERENCESPrimary Bank(Required)Address(Required)City(Required)State(Required)Zip(Required)Bank Contact Person(Required)Phone(Required)Checking Account BalanceBank Fax NumberPlease provide 3 non-fuel credit references with whom you maintain significant balance: Do not provide credit cards or oil companies Company NamePhone NumberFax NumberCityStateCompany NamePhone NumberFax NumberCityStateCompany NamePhone NumberFax NumberCityStateFLEET INFORMATIONEstimated Monthly Fuel Usage $This assists us in establishing an appropriate credit limit for your fleet. If your company spends more than $7,000/month on fuel, you must attach your most current financial statements.Current Fuel ProviderCityStatePhone NumberEMPLOYEE REFERRALName of Employee that Referred You.FirstLastLocation of Employee that Referred YouCityPERSONAL GUARANTYIn consideration of Triplett, Inc. dba 24/7 Travel Store/Fleet Card (“Card Issuer”) financing purchases under the Agreement, the undersigning 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. Guarantor promises to pay Card Issuer for all amounts charged including all finance charges, late charges, returned check charges, collection cost, attorney fees and any other sums which become due under this 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. Direct inquires of businesses where the undersigning 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.Signature(Required)Date(Required) Print Name(Required)First Name Middle Initial Last NameBirthdate(Required) MM/DD/YEARSS#(Required)Social Security NumberAGREEMENT & AUTHORIZED SIGNATUREFor the purpose of obtaining merchandise from Triplett, Inc. dba 24/7 Travel Store/Fleet Card on credit, Applicant authorizes Triplett, Inc. to contact any reference given and inquire about the Applicant’s credit history. Applicant further agrees to notify Triplett, Inc. in writing within five days of any change of ownership, address, telephone, authorized purchasing agent(s), banks, transfer of assets or other facts set forth below. The Applicant agrees to the terms and conditions set forth in this Customer Service Agreement provided with the application and/or provided with the application and/or provided with the Fleet Card. Use of any Fleet Card and/or open charge account issued pursuant to this application confirms Applicant’s agreement to said terms and conditions. Applicant promises to pay Triplett, Inc. for all amounts charged to Applicant’s account. Applicant agrees when Applicant gives access to the Applicant’s Fleet Card account/card that has been issued to Applicant to an employee or friend, Applicant authorizes their use and is responsible for all charges to the account. Applicant agrees that each person who has signed the application is responsible along and together with anyone else signing for all amounts due on the account including all FINANCE CHARGES, late charges, return check charges, collection costs, attorney fees, and any other sums which become due under this agreement to the extent permitted by law. On past due balances, FINANCE CHARGES are computed at periodic rates of 1.5% per month (ANNUAL PERCENTAGE RATE of 18%). Any account considered past due may be on a temporary hold basis until payment is received. Additional information may then be requested to make further charges. All credit sales are made subject to the Kansas Uniform Consumer Credit Code, if applicable. Applicant consents and agrees that any or all terms of this agreement may be changed after notice is given in writing in two billing cycles prior to the effective date of the change. NOTICE TO APPLICANT: DO NOT SIGN THIS AGREEMENT BEFORE YOU READ IT. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT. YOU MAY PREPAY THE UNPAID BALANCE AT ANY TIME WITHOUT PENALTY. Everything that Applicant states in this application is correct to the best of Applicant’s knowledge. Applicant understands that Triplett, Inc. will retain this application whether or not it is approved. Triplett, Inc. is authorized to check Applicant’s credit and to answer questions about the credit experience with Applicant’s account. Upon approval of this application, Applicant agrees to abide by the terms and conditions of sale contained herein.SignatureDate Print NameTitleAny persons signing on behalf of a business attests that the buyer is a valid business entity and that said person is authorized to make this application on the buyer’s behalf.
