Blanchard Valley Farmers Coop - Cardtrol Card Application

SECTION A

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Home Phone *

Social Security # *

Date of Birth *

CO-APPLICANT NAME:

CO-APPLICANT SOCIAL SECURITY #

How Many Years At Current Address: *

Do You Rent Or Own: *

Own
Rent

SECTION B

Employer Name: *

Employer Address: *

Occupation, Employer, Phone Number, How Long Employed: *

SECTION C

How Many Cards Needed? *

Same P.I.N.number on each card?(Check one) *

Yes
No

If not, how many separate P.I.N.numbers?

Do you use: *

Gasoline
Diesel
Both

Maximum gallons per fill-up: *

Do you wish to enter vehicle mileage? *

YES
NO

Do you wish to enter vehicle number? *

YES
NO

By Clicking the Submit button at the bottom of the page you will submit the application to Blanchard Valley Farmers Co-Op.

I AUTHORIZE BLANCHARD VALLEY FARMERS CO-OP TO VERIFY THE ABOVE INFORMATION AND REFERENCES. I ALSO AGREE TO THE TERMS AND CONDITIONS AS FOLLOWS; THE PRODUCTS PURCHASED ON THIS CARD ARE DUE AND PAYABLE ON THE 15TH OF THE FOLLOWING MONTH. IF NOT PAID WITHIN THESE TERMS A SERVICE CHARGE OF 1.5% (AN ANNUAL RATE OF 18%) WILL BE ASSESSED AND THE USE OF THE CARD MAY BE SUSPENDED.

Once your application has been approved, you will have your own BVFC fuel card within days and can be enjoying the benefits and discounts waiting for you.

* Required field