Jiffy Lubefleet application

* denotes required field

Company Details

Company name

Business phone number

Who referred you? (Store street, store city, or person)

Country

State / Province / Region

Address line 1

Address line 2

City

Zip / Postal Code

Federal tax ID

Is your business tax exempt?

First name

Last name

Fleet manager phone number

Fleet manager email

Same as fleet manager

First name

Last name

Accounts payable phone number

Accounts payable email

i.e. States/Provinces/Regions. If you want nationwide coverage, please select the "All [COUNTRY NAME]" option.

Please check any that apply

Purchase order number (PO#)

Vehicle identification number (VIN)

License plate

Unit number

Driver's name

Authorization number

Authorizer (if Authorizer is selected please provide contact info.)

Department

If other selected above

Please tell us what other information is required.

Authorized by (your name)

Authorized on date