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Chevron Gas Credit Card Application Form

In the case of wanting to apply for a chevron gas credit card, the following form has to be completed and submitted.

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Please complete & mail or	 fax to:	 Chevron Canada Limited P.O. Box 9610, Vancouver, B.C. Canada V6B 4G3 
Fax (604) 668-5656	
. 	Page 1 of 4  O:\VN1050-Finance\CAS\Masters\Applications\CD1 Commercial Application0211.docx  CD1 (Feb 11)	 	
 
Commercial Credit Application 
PLEASE COMPLETE IN FULL TO EXPEDITE PROCESSING 
 
 	
COMPANY INFORMATION 	  	 Sole Proprietorship Year business established 	 	 Partnership Year present ownership started 	 	 Limited Company 
Business affiliated with / Controlled by 	
LEGAL BUSINESS NAME 	 Other   	 	
 
NATURE OF BUSINESS 
NAME OF PRINCIPAL (IF SOLE PROPRIETORSHIP) 
 
 
EMAIL ADDRESS: 
 
BILLING ADDRESS  Business Phone Number 
Business Fax Number  ( ) 
( ) 
  CITY      PROVINCE   POSTAL CODE  Cellular Phone number 
Fleet/Operations Manager Name  ( ) 
 
Personal Guarantee Signed? 	 YES   	 NO Financial Statements for 20___ are available. 
Financial Statements attached: 	 YES   	 NO Accounts Payable Contact  Accounts Payable Fax number  
( ) 	
FULL NAMES AND ADDRESSES OF PRINCIPALS, PARTNERS OR COMPANY OFFICERS 	 Name Position/Occupation  Date of Birth  Social Insurance Number 
 Address                                                                                     City                                Postal Code	 MO 
 DAY 
 YR 
  	
 Home Phone  Spouse’s Name 
 OWN HOME 	 	   
 RENT HOME 	 	 Name Position/Occupation  Date of Birth  Social Insurance Number 
 Address                                                                                     City                                Postal Code	 MO 
 DAY 
 YR 
  	
 Home Phone  Spouse’s Name 
 OWN HOME 	 	   
 RENT HOME 	 	ASSETS 
Land & Buildings 
 MARKET VALUE  MORTGAGE  MORTGAGE HOLDER NAME & ADDRESS 	
CREDIT INFORMATION 	NAME  ADDRESS / LOCATION  ACCOUNT NUMBER  TELEPHONE NUMBER 	Current Fuel Supplier       
Main Bank       
Other Trade References:       
 Other Chevron Account Number: 	
PURCHASING INFORMATION 	ESTIMATED MONTHLY DIESEL PURCHASES  ESTIMATED MONTHLY GAS PURCHASES 
 ESTIMATED MONTHLY LUBRICANTS PURCHASES 
Litres                                                         Dollars  Litres                                                               Dollars                                                                               Dollars DELIVERY LOCATION / ADDRESS  	AGREEMENT 	By applying for a Chevron Commercial Account and for the purpose of granting credit and providing credit services, I consent and give authority to Chevron Canada 
Limited to make the usual credit inquiries any time in connection with the credit applied for and to disclose personal information to other credit grantors, reporting and 
collection agencies, affiliated companies, financial institutions, card embossers and electronic bill presentment service providers. I also agree, unless I request otherwise, 
that Chevron may use my information for the purpose of informing me about products or services available from Chevron. The undersigned agrees to abide by the allowed 
credit terms, which may be changed from time to time, and understands that a late payment charge will apply to overdue accounts. The undersigned agrees that it will 
periodically provide to Chevron that financial information or security deemed necessary by Chevron to support any credit extension. If during the life of any agreement 
with Chevron the undersigned's financial capacity becomes impaired or unsatisfactory to Chevron, in the sole judgment of Chevron, advance cash payment or security 
satisfactory to Chevron will be given by the undersigned on demand by Chevron and shipments/deliveries may be withheld until such payment or security is received.  
The undersigned acknowledges that the account will be used primarily for business purposes.  
 
  FOR: SIGNATURE OF CUSTOMER 
 
 
  PRINT COMPANY/ 
AUTHORISED SIGNING 
OFFICER 
 
 
   PARTNERSHIP NAME    
PRINT NAME & TITLE   DATE    20     
  	
PO Box 9610 
Vancouver, BC Canada V6B 4G3 
Tel: (604) 668-5386 or 1-800-331-7353 
Fax :(604) 668-5656

Please complete & mail or	 fax to:	 Chevron Canada Limited P.O. Box 9610, Vancouver, B.C. Canada V6B 4G3 
Fax (604) 668-5656	
. 	Page 2 of 4  O:\VN1050-Finance\CAS\Masters\Applications\CD1 Commercial Application0211.docx  CD1 (Feb 11)	 	
Commercial Credit Application 	continued 	
 	
TAX EXEMPTION INFORMATION (IF APPLICABLE) 	
If M	ARKED 	DIESEL	 is to be authorised in British Columbia, a “COLOURED FUEL ACCOUNT CERTIFICATION” form must be submitted to Chevron prior to authorising Marked 
fuel purchases. Forms can be found at http://www.sbr.gov.bc.ca/documents_library/forms/0438FILL.pdf or by calling Taxpayer Services at 1-877-388-4440. 	
If M	ARKED 	DIESEL	 is to be authorised in Alberta, Declaration number & effective date must be provided. 
DECLARATION NUMBER     EFFECTIVE DATE 	
ALBERTA FARM FUEL DISTRIBUTION ALLOWANCE CERTIFICATE OF ELIGIBILITY NUMBER 	
If you are exempt from any federal or provincial taxes please indicate the exemption type, applicable exemption numbers and enclose copies of the relevant tax certificates.	 	EXEMPTION TYPE      EXEMPTION NUMBER 
 	
  	
INDIVIDUAL CARD CUSTOMISATION 
CARD FEATURES  
 Each driver keeps their own card 
 Each card has a Personal Identification Number (PIN) 
  All product information & card options are linked to this one card 
 A Vehicle number can be embossed on the card (up to 4 digits)  
(This number will also print next to the card number on your Cardlock invoice) 
SITE AUTHORISATIONS (CHOOSE 1 - Applies to all cards on the account) 	
 
   	 All B.C.  
    	 B.C., Alberta & Saskatchewan 
  
    	 Alberta & Saskatchewan 
 	
MARKED FUEL ACCESS? (Applies to all cards on the account) 	 YES  - All customers must complete the TAX EXEMPTION INFORMATION section above               	 NO 	
NUMBER 
OF CARDS PRODUCT INFORMATION 
 CARD OPTIONS 
ON-SITE MANUAL ENTRY 
 VEHICLE #  
Maximum 4 Numeric Digits 
Embossed on cards. Prints on 
invoice  
  	 All Fuels 
 
 Diesel Only 
 
 Gas only  
  
Miscellaneous Number 	
 Yes 	 No 
 
Odometer Number 	
 Yes 	 No 
 
 
PIN Numbers are mandatory and will automatically be assigned to 
each card.**  
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 	
  	 All Fuels 
 
 Diesel Only 
 
 Gas only  
 
  
Miscellaneous Number 	
 Yes 	 No 
 
Odometer Number 	
 Yes 	 No 
 
  
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 
_____|_____|_____|_____ 	
**CUSTOM PIN : PLEASE COMPLETE THE ONLINE ACCOUNT ACCESS SECTION	 ON PAGE 3. ONCE THE ACCOUNT HAS BEEN APPROVED, YOU WILL BE ABLE TO CHANGE YOUR 
PIN NUMBERS ONLINE. 	
ADDITIONAL CARD CUSTOMISATION 	
Please contact our Commercial Account Services at 604-668-5386 or 1-800-331-7353 for additional card & account customisation 
 Purchase restrictions on card  
 Restricted number of transactions per day per card 
 Volume limit per card 
 Volume limit per account 
 Internet access to view transaction data on the Web (also 
see below)  Summary Reports of transactions 
 Purchases by Vehicle Number then Province 
 Purchases by Card Number then Province 
 Purchases by Miscellaneous number then Province 
 Volume & Tax Summary by Province

Please complete & mail or	 fax to:	 Chevron Canada Limited P.O. Box 9610, Vancouver, B.C. Canada V6B 4G3 
Fax (604) 668-5656	
. 	Page 3 of 4  O:\VN1050-Finance\CAS\Masters\Applications\CD1 Commercial Application0211.docx  CD1 (Feb 11)	 	
Commercial Credit Application 	continued 	
 	
ONLINE ACCOUNT ACCESS 	
Chevron Canada Ltd offers online access to enable you to manage your cards and view transactions online. Please indicate your email 
address below to enable access. Instructions will be sent to this email address . 
 
TERMS AND CONDITIONS: 
 
Access to Chevron Canada Limited’s FleetPro cardlock online card management system gives the Customer (“Account Holder”) the ability 
to make changes to their account, including changes to the billing address and phone number, order new cards, make changes to existing 
cards, lock cards, and view and change sensitive PIN information. The Account Holder is responsible for adhering to the Terms and 
Conditions contained herein, in addition to adhering to the procedures and requirements of the FleetPro User Manual. Safeguarding 
sensitive data including PIN information is extremely important and is the responsibility of the Account Holder. Any misuse of the FleetPro 
online card management system or failure to comply with these Terms and Conditions and FleetPro User Manual by the Account Holder or 
its employees, agents or contractors is the sole responsibility of the Account Holder.  
 
 The Account Holder agrees to indemnify and hold Chevron Canada Limited harmless from and against any and all damages, loss or 
liability of whatsoever kind and nature that arises from the misuse of the FleetPro online card management system or the failure to 
follow the requirements or procedures contained in these Terms and Conditions and the FleetPro User Manual, whether by the Account 
Holder or its employees, agents, contractors or those for whom they are responsible in law. 
 
 LOST OR STOLEN CARDS – with access to FleetPro, the Account Holder is responsible for cancelling lost or stolen cards and is liable 
for all purchases incurred until the card is cancelled by the Account Holder. In the event that the Account Holder cannot access their 
account online the Account Holder is responsible for notifying Chevron of the lost/stolen card by calling 604-668-5386 (1-800-331-
7353 24 hours.)  
 
Use of the FleetPro online card management system constitutes agreement to and acceptance of these terms and conditions.	
 	    
  
 
 ACCOUNT NAME   
  
 
 EMAIL ADDRESS    
  
 
  NAME OF USER TO BE GRANTED ADMINISTRATOR ACCESS TO FLEETPRO   
  
 
  SIGNATURE OF CUSTOMER OR AUTHORISED SIGNING OFFICER:   
  
 
  PRINT NAME AND TITLE   
  
 
 DATE     
 
 
CHEVRON CANADA LIMITED AUTHORIZATION INFORMATION FOR BUSINESS PRE-AUTHORIZED DEBIT (“PAD”) 
Authorization of the Payor to Chevron to Direct Debit a Customer Account	
 
 
CUSTOMER PAYOR FINANCIAL INSTITUTION/ACCOUNT INFORMATION 	
 
Branch Number  Institution  Account Number 
 
                    
Name of Canadian Financial Institution:  
Branch: 
   
Branch Address: 
   
City:   Prov:  Postal Code: 
  	
*****         Please attach a sample of your cheque marked “VOID”      ****** 	
Auto Fax invoices 
 Yes       No 
 PAD notification report (Fax one day prior to withdrawal) 
 Yes       No 	
Fax #:  	   -    -    	 Contact Name:

Please complete & mail or	 fax to:	 Chevron Canada Limited P.O. Box 9610, Vancouver, B.C. Canada V6B 4G3 
Fax (604) 668-5656	
. 	Page 4 of 4  O:\VN1050-Finance\CAS\Masters\Applications\CD1 Commercial Application0211.docx  CD1 (Feb 11)	 	
BUSINESS PRE-AUTHORIZED DEBIT AUTHORIZATION 
Terms & Conditions 
 
In this Authorization, “we”, “our” and “us” refers to the Payor indicated on the attached Authorization Information. 
 
We acknowledge that this Authorization is provided for the benefit of Chevron and our Financial Institution and is provided in consideration of our financial 
institution indicated on the attached Authorization Information (the “Financial Institution”) agreeing to process debits against our Account in accordance with 
the Rules of the Canadian Payments Association (the “CPA”). 
 
1. We agree to participate in this Business Pre-Authorized Debit Plan and we authorize Chevron Canada Limited and its successors and assigns 
(“Chevron”) to draw a debit in paper, electronic or other form for the payment of goods or services related to commercial activities of the Payor (a 
“Business PAD”) on our account indicated on the attached Authorization Information (the “Account”) at our Financial Institution.  We authorize the 
Financial Institution to honour and pay such debits.  We agree that any direction we may provide to draw a Business PAD, and any Business PAD 
drawn in accordance with a continuing but revocable written authority given by Payor to Chevron authorizing Chevron to issue PADs against Payor’s 
Account at the Financial Institution (the “Authorization”), shall be binding on us as if signed by us, and, in the case of paper debits, as if they were 
cheques signed by us.  This Authorization is for business purposes only. 
 
2. We may revoke this Authorization at any time by delivering ten (10) business days prior to the next due date of a Business PAD written notice of 
revocation to Chevron.  We acknowledge and agree that this Authorization applies only to method of payment and that revocation of this 
Authorization by either party does not terminate, nullify, or make void any contract that exists between us and Chevron. 
 
3. We agree that our Financial Institution is not required to verify that any Business PAD has been drawn in accordance with this Authorization, 
including amount, frequency and fulfillment of any purpose of any Business PAD. 
 
4. We agree delivery of this Authorization to Chevron constitutes delivery by us to our Financial Institution.  We agree that Chevron may deliver this 
Authorization to Chevron’s financial institution and consent to the disclosure of any information contained in this Authorization to its financial 
institution. 
 
5. We hereby waive the following pre-notification requirements under the Rules of the CPA: 
(a) with respect to fixed amount Business PADs, the ten (10) calendar day written pre-notification (to be given before the due date of the 
first Business PAD and prior to each and every change in the amount or payment(s) date) of the amount to be debited and the due date(s) 
of debiting; 
(b) with respect to variable Business PADs, the ten (10) calendar day written pre-notification (to be given before the due date of every 
Business PAD) of the amount to be debited and the due date(s) of debiting; 
(c) with respect to the Business PAD that provide for the issuance of a Business PAD in response to our direct action (such as, but not 
limited to, a telephone instruction) requesting Chevron to issue a Business PAD in full or partial payment of a billing received by us, the 
ten (10) day pre-notification; and 
- OR - 
(d) we agree to either waive the above-noted requirements or to abide by any modification to the above requirement as agreed to with 
Chevron. 
 
6. We may dispute a Business PAD by providing a signed declaration to our Financial Institution that: 
(a) the Business PAD was not drawn in accordance with this Authorization; or 
(b) 	
this Authorization was revoked in compliance with Article 3 hereinabove. 
 
We acknowledge that, in order to obtain reimbursement from our Financial Institution for the amount of a disputed Business PAD, we must sign a 
declaration to the effect that either (a) or (b) above took place and present it to our Financial Institution up to and including but not later than ten 
(10) business days after the date on which the disputed Business PAD was posted to the Account.  We acknowledge that, after this ten (10) business 
day period, we shall resolve any dispute regarding a Business PAD solely with Chevron, and that our Financial Institution shall have no liability to us 
respecting any such Business PAD. 
 
7. We warrant that all information about our Account is accurate and we shall notify Chevron, in writing, of any change in our Account information 
provided in this Authorization within at least the number of days of our payment terms with Chevron or ten (10) business days prior to the next due 
date of a Business PAD, whichever is less.  In the event of any such change, this Authorization shall continue in respect of any new account to be 
used for Business PADs. 
 
8. We warrant and guarantee that all persons whose signatures are required to sign on the Account have signed this Authorization below. 
 
9. We agree to comply with the Rules of the CPA, or any other rules or regulations which may affect the services described herein, as may be 
introduced in the future, or are currently in effect.  We agree to execute any further documentation which may be prescribed from time to time by 
the CPA in respect of the services described herein. 
 
10. We covenant that we have read and understood and agree to all terms and conditions described above. 	
 Name of Payer 
 
 Per 
 
 Date 	
Per 
 
Signature(s) of Authorized Signing Officer(s) Date
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