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Fuel Card Application (Steps: 1-6)
Select this method if you wish to send us a Scott Fuel Card Application. Simply fill in all the (*) required fields below and press 'send'. We will take your information and respond as soon as possible.

Note: See optional pdf credit application download below.


1) Personal Information:
Complete Name: *
E-Mail Address: *
Social Security #: *
Number/Dependents: *
Applicant Age: *
Number/Cards Desired?: *
Joint Account?: *
If yes, Spouse Name?: ^
Social Security #: ^
Spouse Age: ^

Applicant Current Address
Address: *
City: *
State/Province: *
ZIP/Postal Code: *
Phone: *
Fax:

2) Housing Status
Housing Status: *
Housing Type: *
Monthly Housing Payments *
If Renting, Whom?:

Applicant Former Address ( If less than one year )
Address: *
City: *
State/Province: *
ZIP/Postal Code: *

Address 2: *
City 2: *
State/Province 2: *
ZIP/Postal Code 2: *


3) Bank Accounts:
Name of Bank: *
Bank Address: *
Bank Phone: *
Checking?: *
Savings?: *
Loan?: *
Years with Bank: *

4) Employer Info
Applicant Employer 1
Name of Employer: *
Address of Employer: *
Monthly Income: *
Position(s) Held: *
Years with Employer: *
Work Phone: *

Spouse Employer 2 (if joint)
Name of Employer: *
Address of Employer: *
Monthly Income: *
Position(s) Held: *
Years with Employer: *
Work Phone: *


5) Account Details:
Account Type: *

Allow access to the following fuel: *
Regular: *
Unleaded: *
Premium: *
Diesel: *
All of Above: *

Optional Required Input: *
Identification: *
Odometer Input: *
Variable Code: *

Do you agree with terms?: *


6) Authorization:
I certify that the facts contained in this credit application are true and complete to the best of my knowledge and understand that, if approved, falsefied statements on this application shall be grounds for termination.

By sending this, I hereby authorize Scott Petroleum to perform a credit check and verify all statements contained herin and the references and employers listed above and release the company from all liability for any damage that my result form utilization and such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for credit approval for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

Date of Submission: *
Your Virtual Signature: *
Note: Your IP Address Recorded

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(Optional) PDF Credit Application
[ Acrobat PDF ] Note: If you prefer you can download our PDF Credit Application, complete it and snail mail it in.

Simply download the Commercial or Consumer PDF application to begin. Mail it back in here.





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