 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
New!
Replace or Request New Card!
New!
Corporate Gas Card
Application Form
Instructions:
This online Gas Card application is provided
for your convenience.
Fill out all pertinent information to the best of your knowledge. All fields listed
in red
are required. Your information will remain private and will not be sold or transferred
to anyone outside Lassus, for any reason, except for collection purposes..
Promo Code
|
| Contact
Information: |
| Company
Name |
|
| E-mail Address |
|
| Phone |
|
| Fax |
|
| Street
Address |
|
City
|
State
|
Zip
|
| Yrs.
Established |
|
| Billing
Address: ( If Different ) |
| Street Address |
|
City
|
State
|
Zip
|
| Company
Details: |
| Is Business
Incorporated? |
Yes
|
No
|
| Type
of Business |
|
| Maximum
Credit Applying For |
|
| Parent
Company Information: ( If Different ) |
| Parent Company Name
|
|
| Street Address |
|
City
|
State
|
Zip
|
| Credit
References: |
|
1. Name
|
|
| Street
Address |
|
City
|
State
|
Zip
|
Phone
|
|
2. Name
|
|
| Street
Address |
|
City
|
State
|
Zip
|
Phone
|
| 3. Name |
|
| Street
Address |
|
City
|
State
|
Zip
|
Phone
|
|
Names
of Owners, Partners or Officers:
|
Name
|
Title
|
Name
|
Title
|
Name
Of Bank
|
City
|
State
|
Checking
Acc. No.
|
Savings
Acc. No.
|
Loan
No.
|
Dun.&
Brad. No.
|
| Options
Desired: |
| Prompts (at time of
purchase) |
Sorts (on statement) |
|
|
| Purchases
Allowed On Cards... |
|
Gold
|
Silver |
All Items
EXCEPT
Lottery
Lotto
Money Orders
|
Fuel
Vehicle Related Items
Car Wash
Propane Fuel
Ice |
| Card
Details... |
Vehicle#
(card#) * |
Notation On:
(Optional) ** |
Card
Color |
| |
Card
Statement |
Gold |
|
Silver |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
*
Vehicle # - Default is 1, 2, 3, 4, etc. May be customer’s truck # or employee
#
(Maximum 4 spaces)
** Notation can consist of a name: John
Doe, department: Maint. Dept., or vehicle description: 98 Blue Ford. Will appear
on card and statement to help identify transactions
(Maximum 12 spaces)
Call if more cards are required |
| Note: |
|
NOTE: If an account is authorized to purchase
on "open account",be it understood that all purchases are due and payable 10(ten)
days after date of statement. A finance charge is computed monthly at 1.25% (Annual
Percentage Rate of 15%) and is applied to any unpaid previous balance. In the
event this account becomes delinquent and is turned over for collection, it is
agreed this debtor will pay all costs of collection. If this credit application
is faxed to Lassus Bros. Oil, the applying corporation intends the faxed application
and signature to be construed as original.
I (we) have read and are in agreement with the terms and conditions.
|
|
| |