This fuel card account application (the "application") relates to fuel card and miscellaneous Merchandise ONLY. If approved, short-term credit will be extended by and can be utilized by applicant solely for fuel card and misc. Merchandise purposes. Gold-Eagle Cooperative is not a finance company and expects prompt on-time payment for outstanding balances.
Primary Applicant First Name
Middle Name
Primary Applicant Last Name
Primary Applicant Title (If Applicable)
Primary Applicant Home Phone
Primary Applicant Cell Phone
Primary Applicant Street Address
Primary Applicant City
Primary Applicant State
Primary Applicant Zip Code
Primary Applicant Email
Primary's Social Security Number
Primary's Date of Birth
Primary's Marital Status
Married
Separated
Unmarried
Co-Applicant First Name
Middle Name
Co-Applicant Last Name
Co-Applicant Title (If Applicable)
Co-Applicant Email
Co-Applicant Home Phone
Co-Applicant Cell Phone
Co-Applicant Street Address
Co-Applicant City
Co-Applicant State
Co-Applicant Zip Code
Co-Applicant Social Security Number
Co-Applicant Date of Birth
Co-Applicant Marital Status
Married
Separated
Unmarried
Primary Bank
Bank Branch
Bank Phone
Annual Income
Primary Applicant Signature
Date
Co-Applicant Signature
Date
By typing your name as your signature above, you agree that the following terms will govern any purchases made which are charged to any gas charge account that you may have with Gold-Eagle Cooperative “GEC”.
Send
