Evergreen FS, Inc.
FAST STOP Card Application
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Address
*
Street Address
Street Address Line 2
City
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District of Columbia
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Wisconsin
Wyoming
State
Zip Code
Email Address
*
Phone Number
*
Please enter a valid phone number.
SSN
*
Number of Cards wanted
*
1
2
3
Preferred Driver ID # (4 Digits) (If no preference, one will be assigned to you for fuel transactions)
Preferred Driver ID # (4 Digits) (If no preference, one will be assigned to you for fuel transactions)
Preferred Driver ID # (4 Digits) (If no preference, one will be assigned to you for fuel transactions)
Current Employer
*
Employer Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employer Phone Number
*
Please enter a valid phone number.
When did you start working for your current employer?
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Annual Income
*
Terms & Conditions
The above information is for the purpose of obtaining credit terms and is warranted to be true. I/we agree that EVERGREEN FS, Inc. can and will rely on the information set forth by me/us in this application and that EVERGREEN FS, Inc. is reasonable in doing so. I/we authorize EVERGREEN FS, Inc. to investigate the references listed pertaining to my/our creditor worthiness and financial responsibility. I/we further authorize EVERGREEN FS, Inc. to request consumer reports from consumer reporting agencies to consider this application and to review or collect the account. I/we agree to abide by the terms and conditions set forth in this application and in EVERGREEN FS, Inc.'s Credit Policy, receipt of which is hereby acknowledged. I/we understand and agree that interest at the rate of 24% per annum, or the maximum amount allowed by law, will be assessed on any outstanding balance owed, if not paid according to the terms as stated. Any legal proceedings arising out of any contract made our dealing between the parties is to be processed and submitted to a court in the state of Illinois and be governed by the laws of Illinois. I/we hereby agree to venue in McLean County, Illinois for any action arising out of this agreement. I/we agree that, in the event of legal action against me/us by EVERGREEN FS, Inc. as a result of my/our failing to fulfill any duty or and/or obligation to EVERGREEN FS, Inc., I/will pay any costs, including attorney's fees, incurred by EVERGREEN FS, Inc. in connection with said legal action. By signing below, I/we attest to receiving "Duty to Warn" literature concerning (Liquid Petroleum) LP Gas.
Signature
*
Please verify that you are human
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