Fuel Card Request Form | Ray-Carroll Fuels

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TANK REFILL REQUEST

CUSTOMER ACCOUNT

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Fuel Card Request Form

Name on Account

Account Number

Replacement Card?

Yes

No

*If yes, card number or pin number associated with card:

Type of Card Requested

All Fuel

Tax Exempt Dyed Fuel

Contract Card

Number of Cards Requested

How Can We Get Our Cards To You?

Phone (incase we have questions)

Thanks for submitting!

50/50 Referral Program

Service Station

Become a Customer

Ray-Carroll Fuels

807 West Main

PO Box 410

Richmond, Mo 64085

816-776-3098

rcfuels@ray-carroll.com

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