Fleet Cards

Cliff’s Local Market offers its own Cliff’s Local Market business fleet cards to businesses and municipalities who have multiple vehicles. The business gas cards can be used at any of our locations which is convenient to the customer.

We offer customized billing options, which may include driver information, vehicle identification, odometer readings and more. Invoices can be sent weekly or monthly to customers approved for credit.

For more information about our business gas cards please contact John Lytwynec by email at jlytwynec@cliffordfuel.com.

Please fill out the application below to apply for a Business Fleet Card or click here to download a printable PDF of the application.

Step 1 of 4

Fleet Card Credit Application
1. 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 charge account, if approved for credit, and one or more charge cards from the card issuer.
3. Applicant agrees to the terms and conditions set forth in the Charge Account Agreement. 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 credit report.
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.
Business Credit Information
Full Legal Company Name of Applicant*
Phone Number*
Fax Number*
Company Name to Appear on Account*
Email Address*
DBA or AKA*
Subsidiary of*
Applicant's Taxpayer ID Number*
TIN, FEIN, or SSN
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Business*
Phone Number*
- Check if the billing address is the same as the physical address
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Contact*
Principal(s)/Authhorized Officer(s)*
Title(s)*
In Business Since*
MM slash DD slash YYYY
Monthly Fuel Use*
In Gallons
Number of Vehicles*
Select One*
- Corporation
- Partnership
- Propietorship
- PC or PA
- LLC

Business Bank
Primary Bank*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Contact Person*
Phone Number*
Account Number*

Trade References
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

Designation of Contact Person/Recipient of Reports
Contact Name*
Title*
Phone Number*
Fax Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*
- Use physical address
- Use billing address
Email Address*
Tax Exempt Municipality
Must provide written statement of municipality status & Federal ID Number
- Check Here
Must provide written statement of municipality status & Federal ID Number
Authorization Signature Required
Name*
Date*
MM slash DD slash YYYY
Title*
Captcha

PICK-UP/DELIVERY

PICK-UP/DELIVERY

PICK-UP/DELIVERY

Fleet Cards

Step 1 of 4

Fleet Card Credit Application

Business Credit Information

Business Bank

Trade References

Designation of Contact Person/Recipient of Reports

Tax Exempt Municipality

Authorization Signature Required