Flash Market, Inc.  
 GENERAL INFORMATION
 Legal Name of Business  Trade Name of Business
 Business Street Address
 City  State  Zip  Email
 Phone Cell*  Fax
 PROPRIETOR, PARTNERS OR CORPORATE OFFICERS+ (Please provide an alternate address where we may reach you.)
 Name  1.  2.  3.
 Title               
 Street               
 City, State, Zip               
 Home Phone*               
 Email               
 Social Security #               
 Security Code**               
 Security Do not list in security Do not list in security Do not list in security
+By signing this credit application, I authorize the person(s) listed on the credit application to carry out security-related duties for the company.
Social Security Number required in order to carry out security-related duties for the company.
*Home phone or cell phone number will be called in case of emergency. **Security Code if other than Social Security Number; 4-10 digits.
 DESCRIPTION OF BUSINESS Corporation Partnership Proprietorship  Federal ID#
 Incorporation Date  If subsidiary, name parent company
 BANK & TRADE INFORMATION  Bank Name  Acct#  
 Contact  Phone
 City  State  Zip  Fax     
  Fuel References Preferred
 REFERENCE #1  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 REFERENCE #2  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 REFERENCE #3  Firm Name  Acct#  
 Address  Contact
 Phone
 City  State  Zip  Fax     
 CREDIT INFORMATION  Financial Statement Enclosed**    Yes No - Required if credit line requested more than $10,000
 Credit Line Requested  # Vehicles # Cards  Terms Requested (Weekly, Monthly)
 Listed in Dun & Bradstreet   Yes No  If yes, please list Duns#
 Payment Method: For Payment Methods 1-3, the following banking information is required:
1. AutoPay (ACH)
2. InternetChek
3. Faxed ElectroniChek
4. Business Check
5. Other: 		Checking Account#: Bank ABA/Routing#:
Financial Institution: Bank Phone#:
Branch Location: City & State:
Regarding AutoPay, Fleet One is authorized to initiate payment upon the invoice due date. Regarding Internet and ElectroniChek Authorization, I authorize Fleet One to accept ElectroniChek or Internet Payment as payment for my invoices. Only upon receipt of my signed ElectroniChek, or use of the online payment system, will FleetOne, L.L.C. accept this payment from my checking account.
**Any financial statement submitted with this application will facilitate the establishment of your account and will be Relied upon by Fleet One. Any such statements will be kept strictly confidential.

Permission is herewith granted to obtain credit information from all listed references including my bank. All financial information submitted in support of this new account and credit application is true and complete in all respects. My account is subject to a late charge of 1.5% per month (18% per annum) on all past due invoices. Furthermore, I understand that my account may be turned off if my account is past due and that any collection fees (including attorney fees) incurred by Fleet One, which the parties hereby fix at 33 1/3% of any balance due plus court costs, will be borne by my account.
By signing this credit application and using services of Fleet One, I certify that I am authorized to make this request on behalf of this company, and it is agreed that all purchases will be paid in accordance with the terms & conditions.
I assume personal and individual responsibility and liability, and guarantee payment of all charges due and payable to Fleet One by the company or corporation listed herein. I hereby consent and authorize the use of my consumer credit report in the credit evaluation process.
SIGNATURE OF PROPRIETOR, PARTNER OR CORPORATE OFFICER______________________________________________DATE_______________
PRINT NAME__________________________________________________________________________________________
SIGNATURE OF WITNESS________________________________________________________________________________DATE_______________
PRINT NAME__________________________________________________________________________________________
Click here to read the Terms & Conditions
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