Company Information:

Company Name: *

DBA (Doing Business As):

Business Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number: *

Fax Number:

Email Address: *

Website:

Contact Information:

Primary Contact Name: *

Title/Position: *

Phone Number: *

Email Address *

Billing Information:

Billing Address: (If different from business address)

Address Line 1

Address Line 2

City

State

Zip Code

Accounts Payable Contact Name:

Phone Number:

Email Address:

Fleet Information

Number Of Vehicles in Fleet: *

Types Of Vehicles (e.g., cars, trucks, vans): *

Any Special Instructions Or Requirements

Work Authorization Contact:

Name: *

Title/Position: *

Phone Number: *

Email Address: *

Maintenance Preferences:

Any special instructions or notations regarding vehicle service(s)?

Invoice Distribution:

Who should receive copies of approved and completed invoices?

Name: *

Title/Position: *

Phone Number: *

Email Address: *

Agreement Terms:

Payment Terms: Net 30 days
Preferred Payment Method: Check or ACH

(If Authorized Payable

Authorization:

I, the undersigned, authorize GVT Tire and Auto to verify the information provided above for the purpose of establishing a Fleet/Charge Account. I understand that this information will be used to coordinate services and billing. I acknowledge that it is the responsibility of the customer to promptly update GVT Tire and Auto in writing of any changes to the information provided, including contact details, billing information, and authorized personnel.

Authorized Representative Name: *

Title/Position: *

Date: *

Fleet Account Sign Up

Company Information:

Contact Information:

Billing Information:

Fleet Information

Work Authorization Contact:

Maintenance Preferences:

Invoice Distribution:

Agreement Terms:

Authorization:

Golden Valley

Andover

Corcoran

Savage