Fuel Discount Program

If you have any questions regarding this application please call 603-659-3822 x4327.

Corporate Application Information

Form of Business *

Account Contact Information

Banking Information - Business Checking Account Information for ACH Debit (automatic payments)

Please provide your Bank name and location.  We will ask for the bank checking account number and routing number when you receive the final agreement for signature.
Thank You

Business Credit Card Information

Please provide information below. We will require the card number, expiration date and security code on the back of your card at the time of final agreement signature.
Thank You

Shipping Information

Please ship my cards using: *
If mailing address is different than above please fill out below information.
By checking this button, I approve of the Summary that was sent to me. *