AGRILAND FS Credit Application

AGRILAND FS Credit Application
Type of Account*

IndividualBusinessFAST STOP Fuel Card
Product(s) Requested*

AgronomyAg/Commercial FuelAg/Commercial PropanePropane - Home HeatFeedRetail Products (lawn fertilizer, ice melt, etc.)GrainFAST STOP Fuel Card (select # of cards and Driver ID below)

FAST STOP Card Request
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Check to receive statements via email
Birth Date

MonthDayYear
Social Security #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of cards wanted

12
Preferred Driver ID # (4-digits)
If no preference, one will be assigned to you for fuel transactions)
Promotional Code
*Not required for submission
How did you hear about us?

Individual Applicant Information
Name

First NameMiddle NameLast Name
Phone

Area CodePhone Number
Email
example@example.com
Check to receive statements via email
Birth Date

MonthDayYear
Social Security #
Address

Street Address

PO Box

CityState

Zip Code
Years at this address
OwnRent
Landlord's Name
Landlord's Phone
Present Employer
Present Employer Phone
Current Position
How long have you been employed with this employer?
Annual Income
How did you hear about us?

Business/Corporation Account Information
Company Name
Federal ID
Individual Sole Proprietor Name

First NameLast Name
Social Security #
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Check to receive statements via email
# Years in Business
Billing Contact

First NameLast Name
Position
How did you hear about us?

Credit Reference
Primary Bank
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodeFax Number
Email
example@example.com
Bank Contact

First NameLast Name

Trade Reference
Reference Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodeFax Number
Email
example@example.com

Authorized Signature (Corporation, LLC)
Signature*

Clear

Authorized Signature/Personal Guarantee
Signature*

Clear
Should be Empty: