*required

Company Information

Legal Business Name*

	Same as above
Name To Be Printed On Cards*

Street Address*
City*
État/Province*
Zip/Postal Code*
Telephone Number*	Ex. 555-555-0100
Cell Phone Number	Ex. 555-555-0100
Fax Number	Ex. 555-555-0100
Email Address*

Please indicate the most effective method of contacting you.

Contact Preference*

Years In Business*
Nature Of Business*
Language Preference*

Bank Reference

Bank Name
Address
Account Number
Contact Name
Telephone Number	Ex. 555-555-0100
Fax Number	Ex. 555-555-0100

Credit Information

Estimated Monthly Purchases ($)*
Tax Exempt*	**


Legal Status*
Parent Corporation (if a subsidiary)

If your business is a sole proprietorship or does not have established credit, please provide the name, address, and contact information of the owner (or authorized signor), below. This information will be used for credit evaluation only. No personal guarantee is required.

Applicant’s Name: (Your name here constitutes signature)
Spouses Name (if joint): (Your spouse’s name here constitutes signature)

Home Street Address
City
État/Province
Zip/Postal Code

Billing Options

Payment Frequency & Terms*
Statement Options*
Payment Method*
If you chose Pre-Authorized Debit, you must also complete the section below. Otherwise, please proceed to the Talk To Us section.

Bank Funding Pre-Authorized Debit

Where to find your account information

Transit Branch Number*
Institution Number*
Funding Account Number*
Bank Name*
Branch Name*
Branch Address*
Branch City*
Branch Province*
Branch Postal Code*

Attach Image Of Voided Check*

An image of a void cheque is required to set up PAD payments for your new card account; please attach one here.

Talk To Us

How did you hear about the Shell Fleet Card?

	(Choose all that apply)
	Shell Sales Representative
	Shell Station
	Shell Website
	Advertisement
	Recommendation From Another Business
	Recommendation From Friend Or Family Member

If applicable, please indicate the Site ID or name of the Sales Representative that recommended the card to you

Promotion code

Consent, Terms & Conditions

Click here to read the Consent, Terms and Conditions

I Accept*

Authorized Signing officer(s), Principal(s), Partner(s) or Proprietor(s) title*
Signature (your name here constitutes signature)*

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