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. Your submission of this form will provide us with a secure, password protected document of your information.

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

Customer Information

Company Name(Required)

Company Address(Required)

Street Address City State ZIP Code

Contact Name(Required)

Title(Required)

Phone(Required)

Fax

Email(Required)

Banking Information

Bank Account Name(Required)

Bank Account #(Required)

Bank Name(Required)

Bank Routing # (9 digits)(Required)

Bank Address(Required)

Street Address City State ZIP Code

Contact Name(Required)

Contact Name

Contact Phone(Required)

Image of Voided Check(Required)

Please attach an image of a voided check from the payment account.

Accepted file types: jpg, gif, png, pdf, Max. file size: 3 MB.

Customer hereby agrees to make payment of such amounts as Customer may owe to Carroll Independent Fuel LLC, 2700 Loch Raven Road, Baltimore, MD 21218 (“Issuer”) pursuant to that certain Business Charge Agreement, as amended from time to time between Customer and Issuer. Customer hereby authorizes Issuer to initiate debit or credit entries to Customers demand deposit account at Customer’s bank, and further authorizes Customers’ bank to accept such entries initiated by Issuer and to debit or credit such entries to Customer’s account without responsibility for the correctness of the entries.

PLEASE NOTE: (1) CUSTOMER’S BANK MUST BE A MEMBER OF THE AUTOMATED CLEARINGHOUSE; AND (2) CUSTOMERS MUST ATTACH AN IMAGE OF A VOIDED CHECK TO THE AUTHORIZATION AGREEMENT.

Signature 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.

Authorized on This Date(Required)

Customer (Company Name)(Required)

Customer Signature(Required)

Typing your name above acts as your signature.

Signer's Name & Title(Required)

Payment Agreement

Customer Information

Banking Information