Fuel Card Application 💳

Name*

First NameMiddle InitialLast NameSr, Jr, etc.

Address*

Street Address

PO Box

CityState

Zip CodeCountry

Email*

Confirmation EmailNew accounts will be automatically enrolled in myFS Solution Center, an online portal to access account information. Please provide the email address you wish to use for login information.

Statement Preference*

EmailMail

Phone*

Date of Birth*

MonthDayYear

Social Security Number*

Confirm SSN*

SSN Must Match to Complete Application

Fuel Card Type (select one)*

Please list the Driver Name, secure Driver ID, and the number of cards needed for each driver. Similar to a PIN, drivers will be prompted for their Driver ID during fuel transactions. In addition to the Driver ID, with commercial cards, you may also have us prompt the driver for a Vehicle ID number and/or an Odometer reading.

Driver Prompt*

Driver ID (required)Vehicle IDOdometer

Fleet Reporting*

by Vehicleby Cardby DriverNone

Number of Drivers*

1234+

1st Driver Name*

no special characters

1st Driver ID*

any 4 digits

Number of Cards*

2nd Driver Name*

no special characters

2nd Driver ID*

any 4 digits

Number of Cards*

3rd Driver Name*

no special characters

3rd Driver ID*

any 4 digits

Number of Cards*

Additional Drivers*

Please list the Driver Name, secure Driver ID, and the number of cards needed for each driver, separated by comma. One driver per row, 26 characters maximum for each driver, and no special characters please. Driver ID may be any 4-digit number.

Signature*

I hereby agree that the information given is true, accurate, and complete as of the this date.

Date Signed*

Your Local FAST STOP

How did you hear about the FAST STOP Card?

Existing Customer ID

AGRILAND FS, Inc. Credit Account Policies

Annual Percentage Rate for Purchases (APR)	24%
Periodic Rate	APR divided by 365 (Daily Periodic Rate) multiplied by the number of days in the billing period.
Grace Period and Finance Charges	You can avoid Finance Charges on purchases by paying the entire balance owed each month no later than the payment due date specified on your monthly statement. If you do not pay the entire balance owed each month by the due date, a Finance Charge will be applied to your account.
Method of Computing the Finance Charge	Finance Charges are calculated by multiplying the Periodic Rate by the total of two amounts: (1) the average daily balance of your account during the month (excluding current purchases and finance charges) and (2) the average daily balance of the purchases during the preceding month.
Order of Application of Payments	Payments will be applied first to reduce any finance charges on the account, then to reduce the oldest unpaid balance.
Other Fees	Non-Sufficient Funds and/or returned checks will result in a $35 fee.

Purchases on credit. You may buy goods and services from us on credit. We may, in our sole discretion, restrict the items that can be purchased on credit. We may stop further credit purchases if you are delinquent in paying your credit balance.
Minimum payment. We will send you a statement showing the balance that you owe at the end of each month. You are required to pay the entire balance due by the due date specified on your monthly statement.
Finance charges. The above chart shows our current method of calculating finance charges. We will notify you in advance of any changes to how we will calculate future finance charges.
In case of errors or questions about your statement. If you think your statement is wrong, or if you need more information about a transaction on your statement, write to us at the address listed on your statement as soon as possible. We must receive your letter no later than 60 days after the date of the first statement on which the error or problem appeared. You can telephone us, but doing so will not preserve your rights. In your letter, give us the following information:
- Your name and account number.
- The dollar amount of the suspected error.
- Describe the error and explain, if you can, why you believe there is an error. If you need more information, describe the item you are unsure about.

You do not have to pay any amount in question while we are investigating the suspected error, but you are still obligated to pay the parts of your statement that are not in question. While we investigate your question, we cannot report you as delinquent or take any action to collect the amount you question.

Please keep a copy of these credit account policies for your information.

Fuel Card Type (Salesforce)

ConsumerCommercial

(old) Birth Date

MonthDayYear

(old) CREDIT TERMS: The Individual and/or Company listed above (hereinafter individually and collectively “I”, “me” or “my”) agree to abide by the terms and conditions set forth in this Application and in AGRILAND 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. CREDIT REFERENCE AUTHORIZATION: I understand that the above information is for the purpose of obtaining credit terms and is warranted, to the best of my knowledge, to be true. I agree that AGRILAND FS, Inc. can and will rely on the information set forth by me in this application and that AGRILAND FS, Inc. is reasonable in doing so. I understand that AGRILAND FS, Inc. will retain this application whether or not it is approved. I authorize AGRILAND FS, Inc. to investigate the references listed pertaining to my credit worthiness and financial responsibility and that of the above referenced Company. I further authorize AGRILAND FS, Inc. to request consumer reports from consumer reporting agencies to consider this Application and to review or collect any balance due on the account. LEGAL: Any legal proceedings arising out of any contract made or dealing between the parties is to be processed and submitted to a court in the state of Iowa and be governed by the laws of Iowa. I hereby agree to venue in Polk County, Iowa for any action arising out of this agreement. I agree that, in the event of legal action against me or the Company by AGRILAND FS, Inc. as a result of the failure to fulfill any duty and/or obligation to AGRILAND FS, Inc., I pay any costs, including attorney’s fees, incurred by AGRILAND FS, Inc. in connection with said legal action.

I AGREE

(old) I hereby agree that the information given is true, accurate and complete as of the date of this application submission. *

YES

(old) How did you hear about the FAST STOP Card?

(old) Are you a current AGRILAND FS customer?

YesNo

(old) Preferred Driver ID

(old) Promotional Code

*Not required for submission