Complete and sign the application below to gain savings, simplicity and control for your business fueling needs. We will get back to you with confirmation that your account has been set-up, and help with your driver and vehicle set-up. We even have a video to show your drivers just how to use the app to start saving money and time at the pump. We look forward to having you as part of the Carroll Fuel Network.

If you have questions or need any help with this application, please call 1-800-834-8590 or email info@carrollfuelnetwork.com.

Legal Entity:(Required)

Trading As:(Required)

Billing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Office Phone(Required)

FEIN / SSN (if sole proprietor):(Required)

SIC:

DUNS #:

Approx. Number of Vehicles:(Required)

For special pricing, please check your affiliation.(Required)

If more than one, check the one with which you are most affiliated.

Maryland Motor Truck Association

The Regional Manufacturing Institute

Maryland Construction Network

None

Are you now, or have you previously been a Carroll Fuel customer?(Required)

Yes

Carroll Fuel Account Number(Required)

Carroll Fuel Rep's Name

Gallon Usage Estimate (If Known):

Week:

Month:

Primary Line of Business:(Required)

Years in Business:(Required)

Incorporated In Last 12mo?(Required)

Yes

Purchasing Contact:(Required)

Email:(Required)

Direct Phone:(Required)

Cell Phone:

A/P Contact:(Required)

Email:(Required)

Direct Phone:(Required)

Cell Phone:

Email To Submit Invoices:(Required)

Ownership

(Please provide the following on Principals)

Principal #1:

Name

First Last

Title

SS#

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Principal #2:

Name

First Last

Title

SS#

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Principal #3:

Name

First Last

Title

SS#

Home Address

Street Address Address Line 2 City State ZIP Code

Phone

Credit Terms

(To be determined by Credit Department. May differ from those indicated below)

Requested Amount of Credit

**Standard Fuel Network Terms are EOM Net 10 and collected via Electronic Payment

Credit Terms(Required)

CREDIT TERMS: Account balances are due per terms on invoice. Past due balances can accrue a FINANCE CHARGE of 1 ½% per month (ANNUAL PERCENTAGE RATE OF 18%). Applicant specifically authorizes Carroll Independent Fuel LLC, any division thereof, or any credit reporting agency employed by Carroll Independent Fuel LLC or any division thereof, to investigate, at any time, the references herein listed or any other information stated above to determine applicant’s qualifications for credit. Any check, Electronic Funds Transfer, Credit Card Payment, or Draft which is refused, returned, or declined by the financial institution upon which the payment is drawn will be assessed a fee. In the event that a returned item remains unpaid and legal relief is sought the account holder may also be liable for additional penalties provided under state law, including, but not limited to, an amount up to two (2) times the amount of the returned item. In the event of default, applicant agrees to pay the cost of collection, including court costs & attorney’s fees at the rate of 33% of the total balance due. Acceptance of late or partial payments (even if marked “paid in full”) does not waive Carroll Independent Fuel LLC’s (or any division thereof) right to collect all monies owed to the company. Further, by signing below, (Co-) Applicant consents to the personal jurisdiction and venue of the State of Maryland certify that all the above information is correct and that I fully understand your credit terms and agree to proper payment in consideration of extended credit.

IN CONSIDERATION OF CARROLL INDEPENDENT FUEL LLC, ITS AFFILIATES AND/OR SUBSIDIARIES EXTENDING CREDIT, I/WE, JOINTLY AND SEVERALLY, DO PERSONALLY AND UNCONDITIONALLY GUARANTEE TO CARROLL INDEPENDENT FUEL LLC., ITS AFFILIATES AND SUBSIDIARIES, PAYMENT OF ANY INDEBTEDNESS OR BALANCE OF INDEBTEDNESS OF THE WITHIN NAMED FIRM, ITS AFFILIATES AND SUBSIDIARIES WHICH BENEFIT FROM THE EXTENSION OF CREDIT SO OFFERED HEREIN AND/OR RECEIVED.

Signatures in accordance with Principal Owner(s) or Authorized Person(s); By typing my name in the fields below I agree and understand that transactions and/or signatures in records may not be denied legal effect solely because they are conducted, executed or prepared in electronic form. That if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement.

I have read and agree to the terms and conditions. *(Required)

Signatures in accordance with Principal Owner(s) or Authorized Person(s):

*If the prospective purchaser is a corporation, a duly authorized agent with authority to make this application must sign, if a partnership, one partner must sign, if an incorporated association, a member must sign, if a sole proprietor, the proprietor must sign.

Signature 1:(Required)

Typing your name above acts as your signature.

Name:(Required)

Date:(Required)

Signature 2:

Typing your name above acts as your signature.

Name:

Date:

Signature 3:

Typing your name above acts as your signature.

Name:

Date:

CAPTCHA

Simple Application

Gallon Usage Estimate (If Known):

Ownership

Principal #1:

Principal #2:

Principal #3:

Credit Terms

Signatures in accordance with Principal Owner(s) or Authorized Person(s):