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Fleet Fueling Application

To apply for Pacific Pride's Automated Fueling with Deiter Bros., either complete this online form and click the Submit button or download the Business Credit Application and mail or fax it back to us.

The red * indicates required fields.

   
Owner/President
* Name:
* Home Address:
* City:
* State:
* Zip:
Date of Birth:
* Social Security No:
* Home Phone:
* Email Address:
* Verify Email:
 
Company
* Name:
* Phone:
Fax:
* Company Address:
* City:
* State:
* Zip:
* Billing Address:
* City:
* State:
* Zip:
Accounts Payable Contact:
How Long in Business: Years
* Type:
Estimated Gallons/Month:
(Minimum required usage is 900 gallons per year, which averages 75 gallons per month of all fuel types from all fuel sources.)
Number of Vehicles:
Are you currently using Pacific Pride?
Have you used Pacific Pride in the last 9 months?
* Federal Tax ID/Copy of Business License #(s) or Equivalent:
Additional Comments or Information (Card ID Numbers, Customer Special Requests):
 
Partners
Partner's Name:
Address:
Social Security No:
Partner's Name:
Address:
Social Security No:
 
Trade References
* Trade Reference:
* City:
* State:
* Phone:
* Account Number:
* Trade Reference:
* City:
* State:
* Phone:
* Account Number:
* Trade Reference:
* City:
* State:
* Phone:
* Account Number:
 
Agreement and Guaranty

I have made the above statements for the purpose of obtaining credit. I certify they are true and authorize you to make a credit investigation. Billings shall be issued twice each month and will be due in full within 15 days of invoice date. All purchases made on this account will be for commercial use. I hereby consent to receive communications sent by or on behalf of Deiter Bros. and affiliates via email or fax, with no date of expiration.

THIS AGREEMENT INCLUDES THE TERMS AND CONDITIONS, AND BY MY CHECKING THE FOLLOWING BOX I ACKNOWLEDGE THAT I HAVE READ THOSE TERMS AND WILL ADHERE TO THEM.
* Name:
 
Personal Guarantee
IN CONSIDERATION of the extension of credit to the above named purchaser, and to induce the extension of credit, the undersigned do(es) hereby personally guarantee to Deiter Bros. (hereafter called the Company) the prompt payment, when due, of every claim, credit charge, account, past due service charge or money due which may currently exist and/or hereafter arise in favor of the Company against the purchaser named. This is a continuing guaranty and shall remain in force until revoked by me (us) by notice in writing to the Company, but such revocation shall be effective only as to claims of the Company which arise out of the transactions entered into after its receipt of such notice. This guaranty shall bind and inure to the benefit of, as the circumstances may require, not only to the immediate parties hereto but their respective heirs, executors, administrators, personal representatives, successors in interest and assigns, as well. This obligation shall cover the renewal of any claim, credit charge, account, or money due guaranteed by this instrument or extension of time payment thereof, and shall not be effected by any surrender or release by the Company of any other security held by it for any claim hereby guaranteed. The undersigned further agree(s) to pay any and all reasonable collection agency, attorney, and/or court costs whether or not action is instituted for collection thereof, and if action is instituted for collection, such reasonable attorney fees as the court may award, including any attorney fees on appeal.
 
Credit Report Consent

The undersigned hereby consent(s) to Deiter Bros. use of a non­business consumer credit report for the undersigned in order to further evaluate the credit worthiness as principal(s), proprietor(s), and/or guarantor(s) in connection with the extension of business credit as contemplated by this Credit Application.

The undersigned hereby authorizes Deiter Bros. to utilize a consumer credit report for the undersigned from time to time in connection with the extension or continuation of the business credit accommodation contemplated by this Application.

The undersigned as (an) individual(s) hereby knowingly consent(s) to the use of such credit report consistent with the Federal Fair Credit Reporting Act in 15 U.S.C. @ 1681 et. seq.

Please fill in your name and date and CHECK the box to the right to signify you are the Guarantor.
* Name:
* Date:

All state and federal taxes are included in billing unless proper documentation is on file with Deiter Bros. for states which allow tax exemptions.

  I want state tax exemption and will provide tax exemption documentation. State(s) eligible for tax exemption:

  I do not want state tax exemption and will pay all taxes at pump.

Additional Comments or Information: (Tax exemption info., customer special request):
 

 

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