Fleet Account Sign Up

Company Information:

Company Name: *

DBA (Doing Business As):

Phone As): Email

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 *

Will you be applying for a house charge account?

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

Authorization:

I, the undersigned, authorize Golden Valley Tire & Service 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 Golden Valley Tire & Service in writing of any changes to the information provided, including contact details, billing information, and authorized personnel.

Authorized Representative Name: *

Title/Position: *

Date: *

Company Information:

Contact Information:

Billing Information:

Bank References:

Trade References:

Fleet Information

Work Authorization Contact:

Maintenance Preferences:

Invoice Distribution:

Agreement Terms:

Authorization: