IMPORTANT: Do
not leave this page while filling out the form or you may lose your
information. Once your information is complete, simply click "submit"
and the process is complete.
SECTION 1: CURRENT COMPANY
CONTACT INFORMATION
Are you presently a Pacific
Pride or AmeriNet cardholder?
Yes No
Email Address (so we can
respond to you!):
Full Name of Firm (Purchaser):
Phone Number: Fax Number:
Mailing Address:
Mailing City, State, Zip
Street Address:
Street City, State, Zip
SECTION 2: CURRENT COMPANY
GENERAL INFORMATION
Is your business a
A. Single
Entity (not a subsidiary)
B. Partnership
C. Subsidiary
of a Parent Company
If you answered C above,
please enter the name and address of parent company:
How Long in Business? Years
and Months
Corporation State: Federal ID Number:
Under what other company
name have you operated?
SECTION 3: PREVIOUS EMPLOYMENT
INFORMATION
If in business less than two
years, please give name, address and length of employment for the last five
years:
1)
Business Name:
Business Address:
Business /City/State/Zip:
Business Phone:
Length of Employment: years
2)
Business Name:
Business Address:
Business /City/State/Zip:
Business Phone:
Length of Employment: years
3)
Business Name:
Business Address:
Business /City/State/Zip:
Business Phone:
Length of Employment: years
SECTION 4: CURRENT APPLICANT
INFORMATION
Name of
Applicant/Owner/Officer: Title:
Spouse Name:
Home Street Address:
Home /City/State/Zip:
Home Phone:
Drivers License Number &
State:
Social Security Number: Date of Birth:
Name of Nearest Relative Not Living
With You:
Relationship: Phone Number:
Have you ever filed
bankruptcy?
Yes No
If yes, was it
Personally or
Business ?
When did you file: What City/State:
SECTION 5: REFERENCES
Bank Name and Branch:
Bank City & State:
Bank Phone Number:
Current Petroleum Supplier:
Petroleum Supplier Address:
Petroleum Supplier Phone:
Trade Reference 1:
Account Number: Phone Number:
Trade Reference 2:
Account Number: Phone Number:
SECTION 6: NEW ACCOUNT
INFORMATION:
Estimated monthly usage in
gallons: Amount of Credit Desired $
Accounts Payable Contact
Name:
Accounts Payable Phone Number:
Person to Contact to Make
Arrangements for Cards:
Phone Number: Cell Phone Number:
SECTION 7: ADDITIONAL TERMS
AND CONDITIONS:
1. Cardlock
fueling access cards are used to activate fueling dispensers at individual
Pacific Pride/PrideNet/AmeriNet fueling network locations. These access cards are NOT credit cards. The issuance of credit by ITL is independent
of the process for issuing a network fueling access card.
2. Purchaser
shall be responsible for all purchases by Purchaser or its employees or any
other persons using network cardlock cards issued to Purchaser, regardless of
whether use by any other person is unauthorized or fraudulent unless those
cards are reported immediately as lost, stolen, or misused. Lost, stolen, or misused cards should be
reported by calling ITL Cardlock Billing at (323) 562-3230 AND by faxing
a “request to invalidate” the specific lost, stolen or misused cards to ITL
Cardlock Billing at (323) 560-1170. Cards will be invalidated throughout the Pacific Pride network by
11:59PM on the date of notification.
3. If
there is any change in the ownership of Purchaser or if substantially all of
the assets of Purchaser are sold, Purchaser shall promptly notify Supplier of
such sale and Supplier shall have a lien on all the assets of Purchaser and a
lien on the proceeds of such sale to secure payment of all outstanding sums
owed to the Supplier.
4. Purchaser
represents that it and any person using the Cardlock cards delivered to
Purchaser are and shall be aware of the proper use of the Cardlock system and
shall use safe practices in compliance with the regulations of the local fire
code in the handling of the fuels dispensed from the cardlock system. The
Purchaser agrees to indemnify and hold Supplier harmless from any claims and
costs including, but not expressly limited to, loss for bodily injury and
property damage which may be occasioned by the negligence of misuses of the
cardlock system by the purchaser or any person using the cardlock cards
delivered to the Purchaser hereunder.
5. Supplier
shall use its best efforts to maintain the Cardlock system in good working
order and condition at its expense provided, however supplier shall not be
responsible for any damage of loss which may result from its failure to provide
fuel or the failure of the cardlock system in any manner whatsoever. Purchaser
agrees that it and any person using the cardlock cards delivered to the
Purchaser shall promptly notify supplier of any malfunctioning of the cardlock
system of which Purchaser of such person is aware.
6. Purchaser’s
right to purchase fuel through the cardlock system may be terminated immediately
upon any breach of any of the terms hereof or of any other agreement with
supplier. Upon termination, Purchaser agrees to immediately surrender all
cardlock cards issued to Purchaser and to immediately pay all outstanding sums
owed to supplier. Supplier shall refund any deposit to Purchaser when all cards
are returned and all amounts owing to supplier are paid in full.
7. The
card deposit of $25.00 will not be refunded after three years. Normally during
that time, cards will be reissued at least once and accounts restructured as
business changes.
8. A
$100.00 handing fee will be charged for all checks returned from the bank for
any reason.
Default
Agreement. Should Purchaser default on any obligation
under this agreement and the Supplier refers this account to his attorney for
collection and/or legal action, Purchaser agrees as follows: to pay the
principal due, attorney fees and all costs of any nature incurred by the
Supplier to pursue the delinquent obligation. In addition, 15% of the principal
amount due shall be added to the principal as liquidated damages to cover any
an all-additional expenses to Supplier. In the event of a dispute or litigation
between the parties, it is hereby agreed that jurisdiction and venue shall vest
in Los Angeles County, California, Central District or Orange County,
California, Central District at the sole discretion of the Supplier. All other
venues are hereby expressly waived.
I agree to these Terms & Conditions