24/7 Commercial Fueling Application

Application – 24/7 Commercial Fueling Station

Step 1 of 7

X/Twitter
This field is for validation purposes and should be left unchanged.
In order to establish an account with Valley Energy, you must fill out the form below to apply for an account. You will receive an email confirmation at the email address you provide and the Valley Energy Customer Service staff will contact you shortly. The following information is for the purpose of obtaining credit history and will be kept strictly confidential.
Name of Individual Completing Form*
Are you completing this form for business or personal use?*
- Business (commercial)
- Personal
Cardlock Use Agreement
Today’s Date of Agreement: 10/09/2026.
Valley Energy herinafter referred to as VE within the following agreement terms.
1) RULES/REGULATIONS: USER represents to VE that USER has been instructed in the safe and proper use of VE’s dispensing facilities and has been familiarized with the location and function of the emergency equipment provided by VE. USER also represents to VE that all of USER’s employees and agents who use VE’s equipment will be properly trained on the use of said equipment. Further, USER and all of USER’s employees and agents will comply with the following:

a. Smoking is prohibited on site.
b. Dispensing fuel into any container not approved by the Fire Marshal is prohibited.
c. Fueling vehicles with pilot lights operating is prohibited.
d. Engines must be turned off before fueling.
e. No cell phone use during fueling.

USER agrees to defend, indemnify and hold VE free and harmless from any and all claims, actions, losses, damages, injuries, liabilities and costs (including attorney’s fees) resulting from negligence or misuse of VE’s property and equipment by USER or USER’s employees or agents.

2) TRANSACTION CHARGES: USER hereby accepts the obligation and responsibility for payment for all charges registered to cardlock access cards issued to USER. USER is liable for any and all transactions made on a lost or stolen card for up to 24 hours for VE owned sites and up to 48 hours network wide after VE has been notified that the card is lost or stolen. Notification may be made verbally, but must be confirmed in writing and received by VE at 117 North Bailey Lane, Purcellville, Virginia 20132. WARNING: Personal Identification code numbers (P.I.N.) should not be kept with the fueling card at any time.

3) ACTIVATING WRONG PUMP: Should USER, USER’s employees and/or agents activate the wrong fueling pump, USER agrees to clear the pump before proceeding. USER agrees to be responsible for any fuel that is dispensed as the result of not clearing the pump that was activated in error.

4) COMMERCIAL ACCOUNTS: USER represents that all fuel purchased will be used for business purposes only, and not consumer purposes.

5) ACCOUNT ACTIVATION FEE: A $25.00 account activation fee will be assessed (or $15.00 per card, whichever is greater) to USER’s account upon initial setup or re-activation of an old account. Additional or replacement cards will be billed at $15.00 each.

6) LOCKED OUT ACCOUNTS: If USER’s account is locked out for reason of delinquency, all monies plus a Reactivation Fee of $25.00 must be paid before the account will be reactivated. VE reserves the right to refuse to reactivate past due accounts. If USER’s account must be referred to collection, USER agrees to pay collection cost and attorney’s fees incurred by VE. USER acknowledges that accounts and cards will
be deactivated after 12 months of non-use.

7) FUEL PRICES: USER understands that VE fuel prices are not displayed on any pump at the time of fueling, but are available by calling the VE office. Prices quoted at other fueling facilities are not guaranteed. Prices are set on account basis and may differ from receipt at time of sale.

8) FUEL DISCOUNTS: USER assumes responsibility for damages to equipment due to negligence.

9) AGREEMENT TERMS: Terms of this agreement are subject to change upon written notice by VE to USER. If USER uses any cards after receipt of such notice, then USER’s consent to the changed terms shall be implied.
10) CARD CHANGE AUTHORIZATION*
Please list the names of those who can authorize card changes.
Consent*
I agree to the above Agreement Terms

Card Order Form*

Driver/ Vehicle Description	Vehicle Number	Gallon Limit	Spending Limit	Require Odometer Tracking? (yes or no)	Fuel Type (Ex. Gas, DEF, Diesel)

Please complete this field for each requested card. Click the “+” to add an additional row to the Card Order Form.

Personal Contact Information
Name
First Last
Please complete this field the name for the account is different from the name of the individual completing this form on page one.
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Primary Phone Type*
- Mobile
- Home
- Office
Email*

Business Information
Firm Name*
Type of Business*
Date Established
Owner/Partner/Officer Name*
First Last
Title*
Second Owner/Partner/Officer Name
First Last
Title
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please complete if the business address is not the mailing address.
Primary Business Phone*
Primary Business Phone Type*
- Mobile
- Office
Primary Email*
Accounts Payable
Accounts Payable Contact Name
First Last
Accounts Payable Email
Accounts Payable Phone Number
The information submitted is for the purpose of obtaining credit history and will be kept strictly confidential.
Has the applicant or any of its owners, principals, partners, officers, or directors ever filed a voluntary petition in bankruptcy, been adjudged bankrupt, or made an assignment for the benefit of creditors?*
- Yes
- No
If you answered yes to the question above, please explain.*

Credit Policy Terms and Credit Agreement
- Payments are due upon receipt of invoice.
- A LATE CHARGE may be assessed on all balances over thirty (30) days. This is computed by a periodic rate of 2% (which is an annual percentage rate of 24%) on the portion of the previous balance over thirty (30) days less payments and credits appearing on the statement, plus $50 per month late fee. An account is considered past due when a LATE PAYMENT CHARGE is assessed.
- Any account which becomes past due is subject to termination of automatic fuel delivery WITHOUT NOTICE until the account balance is paid in full.
- All fuel remains the property of Valley Energy until paid in full. Valley Energy reserves the right to reclaim ANY FUEL not paid in full.
- Should past due account(s) require the assistance of a collection agency and/or attorney to obtain payment(s), the credit applicant herein agrees to pay all costs, including any attorney’s fees (40% of outstanding principal balance), associated with collection and any subsequent enforcement action. The applicant also agrees that Virginia law shall apply, and litigation must be filed in the Courts of Loudoun County, Virginia..
- A service charge of $35.00 will be added on any check or eCheck returned by a bank.
I certify that the information contained in this document is true and accurate and is submitted to Valley Energy in conjunction with a request for credit. References listed are authorized to release any credit information to Valley Energy. A copy of this authorization shall be as valid as the original.
Company Name*
Full Name*
First Last Title
Signature*
Your Name
Your Name
Your Name

24/7 Commercial Fueling Application

Application – 24/7 Commercial Fueling Station

Step 1 of 7

Cardlock Use Agreement

Personal Contact Information

Business Information

Accounts Payable

Credit Policy Terms and Credit Agreement

Personal Guaranty

Credit Investigation Authorization

Phone Numbers

Email Address

Address