Fill in the form below for additional information on the eflatbed.com Fuel Card+^SM.

Required fields are displayed in red.

Submitted By:
Name		E-mail
Telephone	( ) - ext
Carrier Information:
Carrier Name		Contact
Address 1		City
Address 2		State	Please Select... ALBERTA ALASKA ALABAMA ARKANSAS ARIZONA BRITISH COLUMBIA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MANITOBA MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA MEXICO NEW BRUNSWICK NORTH CAROLINA NORTH DAKOTA NEBRASKA NEWFOUNDLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NOVA SCOTIA NORTHWEST TERRITORY NEVADA NEW YORK OHIO OKLAHOMA ONTARIO OREGON PENNSYLVANIA PRINCE EDWARD ISLAND QUEBEC RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA SASKATCHEWAN TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING YUKON
Zip		E-mail
Telephone	( ) -	Fax	( ) -
ID		Web Site
Fuel Card Questions
1. Who is your current fuel card provider:
EFS Comdata TCH Transplatinum Other None
A. What are the current payment terms?
B. What is the current fuel card funded transaction fee?
C. What is the current fuel card direct bill transaction fee?
D. What are the current express code fees (checks)?
E. Please state the number of fuel card transactions completed per month.
F. Please state the number of express code transactions completed per month.
G. Are you able to receive cash with this card?			Yes No
2. How many trucks are in your fleet?
3. Type of Carrier:
Local Less than truckload Truckload carrier
4. Are you interested in additional products and services offered by T-Chek? If so, please check the appropriate boxes below.
	Phone Card
	Funds Distribution (ATMJ, payroll card options, debit card options, etc.)
	e-Stop Fuel Information Tool kit (Truckstop and wholesale fuel price information)
	Fuel Management Services
	Advantage Fuel Network (Free transaction fee paid program)
	Regulatory and Compliance Services (Fuel tax services, driver log services, etc)
Software / Technical Questions
1. What operating system are you currently using?
2. What industry software are you currently using?
3. If a software system, which one?
4. Do you process EDI shipments?			Yes No
5. Do you process payroll and fuel tax in-house?			Yes No
6. Do you have Internet access?			Yes No

For additional questions, please call Stacey Schultz at 1.877.767.2435 ext. 3037

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