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? * Required

Yes

No

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

Type of Card Requested * Required

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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