Fleet Application Form

FLEET SERVICE APPLICATION
Clear Billing Solutions – Billing for Jiffy Lube stores info@ClearBillingSolutions.com Phone: (855) 939-6645 Fax: (866) 422-2870
Company Name:		Phone:
Contact Name:		Mobile Phone:
Address 1:		Fax:	Fax must be in ###-###-#### format
Address 2:		Email:
City:		Business Type:
State:		Cash Account:
Zip:		Add separate billing information?

Trade References
List three	Trade Reference 1:	Trade Reference 2:	Trade Reference 3:
(Vendors who extend open credit to your company.)	Account #:	Account #:	Account #:
Do not list financial institutions.	Phone:	Phone:	Phone:
	Fax: Fax must be in ###-###-#### format	Fax: Fax must be in ###-###-#### format	Fax: Fax must be in ###-###-#### format

Business and Tax Information
Years in Business:		Tax ID:
Tax Exempt:		Tax Exempt Number:
Number of Vehicles:		Invoice restrictions?	Do you require specific information on your invoices (i.e. PO#, Unit#, Auth Name, VIN) or want any restrictions?
State(s) or areas where service is desired:

Sign and Submit
2011 Jiffy Lube International, Inc. Jiffy Lube and Jiffy Lube Signature Service are registered trademarks of Jiffy Lube International, Inc. All rights reserved. Fleet Agreement This agreement authorizes Jiffy Lube service centers to perform services to your fleet vehicles in exchange for timely payments for services rendered. A statement is delivered the first week of every month, and will include all services rendered, including services still outstanding from a previous month. Statements will be delivered via email unless otherwise requested. Payment is expected within twenty (20) days from the statement date and a 3% fee may be assessed against any past due amounts shown on the statement. We reserve the right to use a collection agency per our discretion, if this is deemed necessary a 20% fee will be added to each invoice to cover the cost of collections. Written notice to Clear Billing Solutions, LLC is required if billing address changes. Written notice to Clear Billing Solutions, LLC is required upon sale or transfer of any fleet vehicle. Failure to do so will obligate you for any charges after the transaction date. Written notice to Clear Billing Solutions, LLC is required if any company employee using personal vehicles under its fleet account is transferred, terminated, or for any reason is no longer employed by the company. Failure to do so will obligate you for any charges after the transaction date. You have thirty (30) days from the Statement Date to notify Clear Billing Solutions, LLC of any Disputed Services. MAIL CHECKS TO: JIFFY LUBE – CLEAR BILLING SOLUTIONS PO BOX 12194 ROANOKE, VA 24023 855-939-6645
By entering your name above and clicking submit, you certify that the information provided is accurate and complete to the best of your knowledge. You authorize Clear Billing Solutions, LLC to process this application, which may include a credit check, and contact references as needed. You also agree to the terms outlined in the Fleet Agreement above and acknowledge responsibility for any charges incurred under this account. ^*By checking this box, you agree to receive SMS messages related to your fleet application, service approvals and and general account activity. Messaging and data rates may apply. Message frequency varies. Reply STOP to unsubscribe.
Signature:		Date: