Fleet Application

[insert take5 MFC logo]

Company Details

Company Name*

Business Phone Number*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tax ID*

Years In Business*

Is Your Business Tax Exempt?*

If yes, we need to receive a COPY of your exemption certificate

Yes
No

Contact Information

Fleet Manager Name*

First Last

Fleet Manager Phone Number

Fleet Manager Email*

Accounts Payable Contact*

First Last

Accounts Payable Phone Number

Accounts Payable Email*

Send Online Account Access To:*

Fleet Manager
Accounts Payable

Trade References

Please list vendors who extend credit to your company. Do not list financial institutions.

Reference 1

Company Name*

Email

Phone*

Fax

Account Number

Reference 2

Company Name*

Email

Phone*

Fax

Account Number

Reference 3

Company Name*

Email

Phone*

Fax

Account Number

Additional Details

Referred By Store

Number Of Vehicles*

Service Area Coverage*

i.e. Cities, States. If you want nationwide coverage, please enter “All”

Account Restrictions

(If there are any)

Information Required on Invoices

Please Check All That Apply

PO
VIN #
License Plate
Unit #
Authorizer (if Authorizer is selected please provide contact info.)
Other

Authorizer Name

Authorizer Phone Number

If Other Selected Above

Please us what other information is required.

Full Speed Automotive Fleet Agreement Terms

This agreement does not require you to have your vehicles serviced at a Full Speed Automotive Service Center; however, it does authorize Full Speed Automotive to service your fleets in exchange for timely payments for services rendered. Billing is handled by MyFleetCenter. A statement is delivered the first week of every month, and will include all services rendered, including services still outstanding from a previous month. Statements will be delivered via e-mail or fax unless otherwise requested. Payment is expected within thirty (30) days from the statement date and a late charge of five (5) percent or $20, whichever is higher, can be assessed against any past due amounts shown on the statement. Written notice to MyFleetCenter is required upon sale or transfer of any fleet vehicle. Failure to do so will obligate you for any charges after the transaction date. YOU HAVE THIRTY (30) DAYS FROM THE STATEMENT DATE TO NOTIFY MYFLEETCENTER OF ANY DISPUTED SERVICES. The customer agrees to pay any and all collection and legal fees incurred by Jiffy Lube, regardless of whether legal action is taken.

It is agreed and understood that payments shall be remitted to: MyFleetCenter, PO Box 620130, Middleton, WI 53562. The information provided in this application and any other information provided to Full Speed Automotive/MyFleetCenter by the applicant is assumed to be accurate and complete and shall remain the property of Full Speed Automotive/MyFleetCenter. You hereby authorize Full Speed Automotive/MyFleetCenter to investigate and confirm your credit experience and send marketing messages via email. Use of your account indicates acceptance of the terms of this agreement.

Midas Fleet Agreement Terms

This agreement does not require you to have your vehicles serviced at a Midas Service Center; however, it does authorize Midas to service your fleets in exchange for timely payments for services rendered. Billing is handled by MyFleetCenter. A statement is delivered the first week of every month, and will include all services rendered, including services still outstanding from a previous month. Statements will be delivered via e-mail or fax unless otherwise requested. Payment is expected within thirty (30) days from the statement date and a late charge of five (5) percent or $20, whichever is higher, can be assessed against any past due amounts shown on the statement. Written notice to MyFleetCenter is required upon sale or transfer of any fleet vehicle. Failure to do so will obligate you for any charges after the transaction date. YOU HAVE THIRTY (30) DAYS FROM THE STATEMENT DATE TO NOTIFY MYFLEETCENTER OF ANY DISPUTED SERVICES. The customer agrees to pay any and all collection and legal fees incurred by Jiffy Lube, regardless of whether legal action is taken.

It is agreed and understood that payments shall be remitted to: MyFleetCenter, PO Box 620130, Middleton, WI 53562. The information provided in this application and any other information provided to Midas/MyFleetCenter by the applicant is assumed to be accurate and complete and shall remain the property of Midas/MyFleetCenter. You hereby authorize Midas/MyFleetCenter to investigate and confirm your credit experience and send marketing messages via email. Use of your account indicates acceptance of the terms of this agreement.

Jiffy Lube Fleet Agreement Terms

This agreement does not require you to have your vehicles serviced at a Jiffy Lube Service Center; however, it does authorize Jiffy Lube to service your fleets in exchange for timely payments for services rendered. Billing is handled by MyFleetCenter. A statement is delivered the first week of every month, and will include all services rendered, including services still outstanding from a previous month. Statements will be delivered via e-mail or fax unless otherwise requested. Payment is expected within thirty (30) days from the statement date and a late charge of five (5) percent or $20, whichever is higher, can be assessed against any past due amounts shown on the statement. Written notice to MyFleetCenter is required upon sale or transfer of any fleet vehicle. Failure to do so will obligate you for any charges after the transaction date. YOU HAVE THIRTY (30) DAYS FROM THE STATEMENT DATE TO NOTIFY MYFLEETCENTER OF ANY DISPUTED SERVICES. The customer agrees to pay any and all collection and legal fees incurred by Jiffy Lube, regardless of whether legal action is taken.

It is agreed and understood that payments shall be remitted to: MyFleetCenter, PO Box 620130, Middleton, WI 53562. The information provided in this application and any other information provided to Jiffy Lube/MyFleetCenter by the applicant is assumed to be accurate and complete and shall remain the property of Jiffy Lube/MyFleetCenter. You hereby authorize Jiffy Lube/MyFleetCenter to investigate and confirm your credit experience and send marketing messages via email. Use of your account indicates acceptance of the terms of this agreement.

Big O Tires Fleet Agreement Terms

This agreement does not require you to have your vehicles serviced at a Big O Tires Service Center; however, it does authorize Big O Tires to service your fleets in exchange for timely payments for services rendered. Billing is handled by MyFleetCenter. A statement is delivered the first week of every month, and will include all services rendered, including services still outstanding from a previous month. Statements will be delivered via e-mail or fax unless otherwise requested. Payment is expected within thirty (30) days from the statement date and a late charge of five (4) percent or $50, whichever is higher, can be assessed against any past due amounts shown on the statement. Written notice to MyFleetCenter is required upon sale or transfer of any fleet vehicle. Failure to do so will obligate you for any charges after the transaction date. YOU HAVE THIRTY (30) DAYS FROM THE STATEMENT DATE TO NOTIFY MYFLEETCENTER OF ANY DISPUTED SERVICES. The customer agrees to pay any and all collection and legal fees incurred by Big O Tires, regardless of whether legal action is taken.

It is agreed and understood that payments shall be remitted to: MyFleetCenter, PO Box 620130, Middleton, WI 53562. The information provided in this application and any other information provided to Big O Tires/MyFleetCenter by the applicant is assumed to be accurate and complete and shall remain the property of Big O Tires/MyFleetCenter. You hereby authorize Big O Tires/MyFleetCenter to investigate and confirm your credit experience and send marketing messages via email. Use of your account indicates acceptance of the terms of this agreement.

Authorized Digital Signature

Authorized By (your name)*

Authorized On Date*