Fuel Card Application
Do you own over 80% of this business?
Please Select
Yes
No
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Please input the Names and Email Addresses of ALL Owners of the business.
This application requires multiple signatures for all owners. An assigned document will be sent to all owners listed below, in the order they are submitted.
Owner 1 Name
*
First Name
Last Name
Owner 1 Email
*
example@example.com
Owner 2 Name
*
First Name
Last Name
Owner 2 Email
*
example@example.com
Owner 3 Name
First Name
Last Name
Owner 3 Email
example@example.com
Owner 4 Name
First Name
Last Name
Owner 4 Email
example@example.com
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Applicant Company Information
Owner Name
*
First Name
Last Name
Applicant Company Name
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Company Type
*
"C" Corp
"S" Corp
State of Incorporation
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Federal Tax ID
*
In Business Since:
Current Industry (Select all that apply)
*
FedEx Ground P&D
FedEx Ground Linehaul
Amazon DSP
Bread
EMS
Waste Management
Other
For FedEx Contractors:
Number of years with FedEx
V Number
Terminal Code
Number of Drivers
*
Number of Units in Fleet
*
Max Number of Routes
*
Average Daily Miles per Route
*
Weekly Revenue Amount
*
Are you a Hello Truck Lease client?
*
Yes
No
Are you a Groundcloud customer?
*
Yes
No
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Ownership
Owner Information
Owner Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
% Ownership
*
If your ownership is less than 80%, please return to the first page to make a new selection.
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residence Phone Number
*
US Citizen?
*
Yes
No
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Questions
Please answer the following with regard to the Owner.
1. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?
*
Yes
No
If yes to please describe.
Owner Initials
*
2. Have you been arrested in the last 6 months for any criminal offense?
*
Yes
No
If yes, please describe.
Owner Initials
*
3. Are you suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency?
*
Yes
No
4. Have you or has ANY business controlled by you ever filed for bankruptcy protection?
*
Yes
No
5. Are you or is ANY business controlled by you presently involved in any legal action (including divorce)?
*
Yes
No
6. Are any tax filings or any of your obligations currently delinquent?
*
Yes
No
If yes, is the debt on an IRS-approved payment plan?
Yes
No
7. Have you ever settled a debt for less than the full balance owed?
*
Yes
No
If yes, please provide an explanation, including original amount, amount owed, and settlement amount.
If the answer to any of the previous questions is "Yes," please provide further explanation in the space below.
If the answer to any of the previous questions is "Yes," please upload any supporting documents below.
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Questions
Please answer the following with regard to the Applicant Company.
1. Is the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency?
*
Yes
No
2. Has the Applicant and/or any one or more of its Affiliates ever filed for bankruptcy protection?
*
Yes
No
3. Is the Applicant and/or any one or more of its Affiliates presently involved in pending legal action?
*
Yes
No
4. Are any business tax filings of obligations currently delinquent?
*
Yes
No
5. If yes, is the debt on an IRS-approved payment plan?
*
Yes
No
If yes, please provide a copy of the plan.
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6. Has your business ever settled a debt for less than the full balance owed?
*
Yes
No
If yes, please provide an explanation, including original amount, amount owed, and settlement amount.
7. Is your FedEx contract currently under a Letter of Assurance, an Opportunity to Cure, Termination Review, or Termination Approval with FedEx? Or has your FedEx contract been under review for termination within the last 12 months?
*
Yes
No
If the answer to any of the previous questions is "Yes," please provide further explanation in the space below.
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Authorization
Applicant Company hereby authorizes Route Consultant Purchasing Alliance to obtain additional credit information about the company and its principals from banks, credit unions and other creditors, and to make inquiries in connection with this application, all of which are authorized to release such information concerning the Applicant Company and/or the principal(s) as requested as part of a credit investigation. Principals understand and agree that a consumer credit report will be obtained in connection with this application and may also be subsequently obtained, along with updated creditor references, as part of a periodic credit review by Route Consultant Purchasing Alliance. The person(s) signing below on behalf of the Applicant Company confirms that all the information in this application is true, complete and correct and also confirms that the person(s) signing below are authorized to make this application and to agree to the foregoing on behalf of the Applicant Company. A photostatic or facsimile copy of this authorization shall be as valid as the original.
Signatures
By signing below, you are signing in your official capacity as an owner/officer of the Applicant Company. Additionally, you acknowledge that Route Consultant Purchasing Alliance reserves the right to request additional information based on answers provided.
Signature of Owner
*
Printed Name
*
Social Security Number
*
Company Title
*
Date
*
-
Month
-
Day
Year
Date
Driver's License
*
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Application is not complete without the upload of a valid driver's license.
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By selecting below, I certify that all information is true to the extent of my knowledge. I also understand that RCPA reserves the right to request additional information about the owner(s) or business at their discretion.
*
I acknowledge
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