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WEX PRIVATE SITE ENROLLMENT PACKET <br />Choose the Purchasing Entity's program: <br />Private Site: Complete sections A, B, C & if relevant, G <br />Private Site Rebilling: Complete sections A-E & if relevant, G <br />Sign and date the agreement <br />Email to: merchantapplications@wexinc.com; <br />or Fax to: 1-207-253-1379; <br />or Mail to: Merchant Operations <br />PO Box 639, Portland, ME 04101 <br />Allow 3-5 Business Days for setup. WEX is unable to complete same -day setups. <br />Select all that apply: <br />❑ New Set-up — First time Setup <br />❑ Additional Site Set-up <br />❑ Additional Account Set-up <br />Adding accounts to already existing sites <br />ACCOUNTA. •• • <br />Account Number (found on Purchasing Entity's billing invoice): <br />(If more than one account attach additional account information. All account numbers are needed in order to ensure correct set-up) <br />Fleet name (legal name of business or DBA): <br />Fleet Contact (first name, last name): <br />Title: <br />Fleet Contact Phone Number: Fax Number: <br />Email Address: <br />B. EQUIPMENT INFORMATION <br />Equipment Vendor (check one): ❑ ComData <br />❑ItFuel Master !❑ GasBoy !❑ MultiForce ■❑ OPW/Petro Vend <br />Equipment Name, Model and Software (be specific): <br />C. SITE INFORMATION <br />Number of Sites: <br />Provide a list of sites with the following information: (If more than one location, attach additional site information) <br />Company Name: <br />Physical Address: <br />City: <br />State: <br />Zip: <br />Site Time Zone (check one): ❑ Eastern ❑ Central <br />❑ Mountain ❑ Pacific <br />Contact Name: <br />Phone Number: <br />Email Address: <br />MASTER AGREEMENT No. 00819 — FLEET CARD SERVICES PAGE 60 OF 138 <br />