Fuel Card Order Form Valley Energy 24/7 Commercial Fueling If you wish to request more than 5 cards at a time, please contact Valley Energy directly at 540-338-6457 or info@valleyenergy.org. Commercial Fueling Card Order Form Step 1 of 7 14% Account NumberCompany NameName(Required) First Last Phone(Required)Email(Required) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Authorized Contact First Last Number of Requested Fuel Cards(Required)Please enter a number from 1 to 5.If you would like to request more than 5 cards at a time, please contact Valley Energy at 540-338-6457 or email info@valleyenergy.org Card 1Driver or Vehicle Description(Required)Vehicle NumberFuel Requirements(Required) Gas Diesel Dyed Diesel D.E.F. Select AllGallon Limitnot requiredDollars Per Day Limitnot requiredRequire Odometer Tracking(Required) Yes No Card 2Card 2 - Driver or Vehicle Description(Required)Card 2 - Vehicle NumberCard 2 - Fuel Requirements(Required) Gas Diesel Dyed Diesel D.E.F. Select AllCard 2 - Gallon Limitnot requiredCard 2 - Dollars Per Day Limitnot requiredCard 2 - Require Odometer Tracking(Required) Yes No Card 3Card 3 - Driver or Vehicle Description(Required)Card 3 - Vehicle NumberCard 3 - Fuel Requirements(Required) Gas Diesel Dyed Diesel D.E.F. Select AllCard 3 - Gallon Limitnot requiredCard 3 - Dollars Per Day Limitnot requiredCard 3 - Require Odometer Tracking(Required) Yes No Card 4Card 4 - Driver or Vehicle Description(Required)Vehicle NumberCard 4 - Fuel Requirements(Required) Gas Diesel Dyed Diesel D.E.F. Select AllCard 4 - Gallon Limitnot requiredCard 4 - Dollars Per Day Limitnot requiredCard 4 - Require Odometer Tracking(Required) Yes No Card 5Card 5 - Driver or Vehicle Description(Required)Card 5 - Vehicle NumberCard 5 - Fuel Requirements(Required) Gas Diesel Dyed Diesel D.E.F. Select AllCard 5 - Gallon Limitnot requiredCard 5 - Dollars Per Day Limitnot requiredCard 5 - Require Odometer Tracking(Required) Yes No CAPTCHA
