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
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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
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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.**
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_____|_____|_____|_____
_____|_____|_____|_____
_____|_____|_____|_____
All Fuels
Diesel Only
Gas only
Miscellaneous Number
Yes No
Odometer Number
Yes No
_____|_____|_____|_____
_____|_____|_____|_____
_____|_____|_____|_____
_____|_____|_____|_____
_____|_____|_____|_____
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**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
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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
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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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