Reso 2021-3185 - Laserfiche WebLink

Home Browse Search

D. VISITING FLEET •• •N (Rebilling Only) If the Purchasing Entity will be allowing fleets other than their own to fuel at their Private Site Iocation(s), please provide the following information for each visiting fleet. Account Name: Account Number: Account Name: Account Number: Account Name: Account Number: WEX BANKING AUTHORIZATION FORM (Rebilling Only) ACCOUNTE. BANK O • Private site owner/operator hereby authorizes and requests WEX to make payments of amounts owing to private site owner/operator by WEX by initiating credit entries to private site owner/operator's demand deposit account at the Bank indicated below ("private site owner/operator's bank"), and authorizes and requests private site owner/operator's bank to accept any credit entries initiated by WEX to such account without responsibility for the correctness thereof. In the event of an overpayment or payment in error, private site owner/operator hereby authorizes WEX to initiate a debit entry to the account for each overpayment or payment in error. It is understood that for purposes of this Agreement, the term "private site owner/operator's bank" shall mean and include the bank identified below by private site owner/operator and any successor bank identified to WEX (i) in a Notice of Change provided to WEX by any Automated Clearing House Association processing credit or debit transactions under this Agreement, or (ii) by private site owner/operator, whether orally or by other non -written means. Any such notification to WEX shall be effective only with respect to entries credited to private site owner/operator's account by the Bank after receipt of such notification and a reasonable time to act upon such notice. Private site owner/operator agrees and acknowledges that WEX will not be liable to private site owner/operator for any damages resulting from the performance or the failure to perform of any Automated Clearing House Association. Funds from the visiting fleet transactions will be automatically deposited in the private site owner/operator's bank account via ACH 30 days after the transaction posts in the WEX system. Bank Name and Address ABA Routing Number Account Name Account Number IMPORTANT: FOR REBILLING ONLY, PLEASE ATTACH A VOIDED CHECK IMPORTANT: FOR REBILLING ONLY, PLEASE ATTACH A COMPLETED W-9 AND IF A PURCHAING ENTITY HAS INCOME GENERATED FROM CALIFORNIA SOURCES, THEY ARE REQUIRED TO COMPLETE AND RETURN FORM 590 WEX must receive a completed W-9 and Form 590 in order to process application. AUTHORIZED PRIVATE SITE OWNER/OPERATOR: The undersigned represents and warrants to WEX that all of the terms and conditions of this WEX Private Site Program Application consisting of this entire document in addition to any other document or addendum including the EX Private Site Program Application have been reviewed in their entirety, are true and correct, and set forth the agreement between WEX and the private site owner/operator. Additionally, the undersigned represents and warrants that he or she has authority to sign and to bind Merchant to the terms of this Application. Also, the undersigned represents that the undersigned has the authority to provide information and execute this Application on behalf of the private site owner/operator. The Agreement shall only become effective upon WEX's acceptance of the Agreement and the Application at its headquarters following approval, and the assignment to private site owner/operator of a private site owner/operator processing identification number. The private site owner/operator further affirms that they are establishing a credit card processing relationship with the processor indicated on the attached WEX private site application. Once WEX begins processing credit cards through this processor, our company does not intend to process any transactions through a processing agreement with a branded petroleum marketer. Signature Printed Name Title Date MASTER AGREEMENT No. 00819 — FLEET CARD SERVICES PAGE 61 OF 138