HomeMy WebLinkAbout183-26 RESOLUTIONPage 1
113 West Mountain Street
Fayetteville, AR 72701
(479) 575-8323
Resolution: 183-26
File Number: 2026-2574
A RESOLUTION TO APPROVE A FUEL CARD PROGRAM CONTRACT WITH CORPAY
TECHNOLOGIES OPERATING COMPANY, LLC, PURSUANT TO AN OMNIA COOPERATIVE
PURCHASING CONTRACT, THROUGH JUNE 30, 2029, AND ANY FUTURE RENEWALS
WHEREAS, the City currently uses WEX Bank for fuel card services utilizing a statewide contract through the State
of Arkansas that will expire on September 7, 2026; and
WHEREAS, the Corpay contract was solicited through OMNIA Partners Cooperative and allows the City to set rules
for how the card can be used, how often and when, giving the City flexible control limits; and
WHEREAS, Corpay also utilizes and integrates with the existing Fleet Management solution FASTER and the Fleet
Telematic system, Samsars, with extra tracking capabilities that will result in streamlined operations and organization
for the City’s Fleet, and will help the Fleet Division obtain more precise, thorough and accurate information to track the
fuel usage for each individual vehicle in real time.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE,
ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Mayor Rawn to sign a contract
with Corpay Technologies Operating Company, LLC, pursuant to an OMNIA cooperative purchasing contract, to
enable the City to participate in a fuel card program through June 30, 2029, and any future renewals.
PASSED and APPROVED on August 18, 2026
Approved:
_______________________________
Molly Rawn, Mayor
Attest:
_______________________________
Kara Paxton, City Clerk Treasurer
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
Mailing address:
113 W. Mountain Street
Fayetteville, AR 72701
www.fayetteville-ar.gov
CITY COUNCIL MEMO
2026-2574
MEETING OF AUGUST 18, 2026
TO: Mayor Rawn and City Council
THROUGH: Steven Dotson, Chief Financial Officer
FROM: Amanda Beilfuss, Procurement Director
Ross Jackson, Fleet Operations Superintendent
SUBJECT: Approval of Fleet Fuel Card Application
RECOMMENDATION:
A resolution for approval of a credit application and for the use of Corpay Technologies Operating Company,
LLC (Fuelman) for Fleet fuel card services within the approved operating budget, utilizing OMNIA cooperative
purchasing contract #R260401, through June 30, 2029, and any future renewals.
BACKGROUND:
The City currently uses WEX Bank for fuel card services utilizing a statewide contract through the State of
Arkansas. That contract is set to expire on September 7, 2026.
The Corpay (Fuelman) contract was competitively solicited through OMNIA Partners Cooperative. This
contract allows the City to set rules for how the card can be used, how often and when, giving the City flexible
control limits. Corpay (Fuelman) also utilizes and integrates with our existing Fleet Management solution
FASTER and our Fleet Telematics System, Samsara. The extra tracking capabilities will result in not only
streamlined operations and organization for the City’s Fleet, but the Telematics integration will help the Fleet
Division obtain more precise, thorough, and accurate information to track the fuel usage for each individual
vehicle, in real time.
DISCUSSION:
Corpay fuel cards are accepted by all local fueling stations and provide access to a large fleet card network.
The City will utilize a retail-based pricing program that includes discounts per gallon, based on billing terms.
Utilizing the Weekly Net 14 option will give the City the maximum discount per gallon offered. This will give the
City a per-transaction discount as opposed to volume-based rebates.
BUDGET/STAFF IMPACT:
There is no immediate expense. Funds for fuel Citywide are approved with each annual budget.
ATTACHMENTS: 3. Staff Review Form, 4. Corpay - Fuelman Application, 5. 2026 Gas-diesel Excise Tax
Exemption Certificate - 2026 FY, 6. 2027 Gas-diesel Excise Tax Exemption Certificate - 2027 FY, 7.
Corpay/OMNIA Lead Agency Award Letter
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
Page 1
City of Fayetteville, Arkansas
Legislation Text
113 West Mountain Street
Fayetteville, AR 72701
(479) 575-8323
File #: 2026-2574
A RESOLUTION TO APPROVE A FUEL CARD PROGRAM CONTRACT WITH CORPAY
TECHNOLOGIES OPERATING COMPANY, LLC, PURSUANT TO AN OMNIA
COOPERATIVE PURCHASING CONTRACT, THROUGH JUNE 30, 2029, AND ANY
FUTURE RENEWALS
WHEREAS, the City currently uses WEX Bank for fuel card services utilizing a statewide contract
through the State of Arkansas that will expire on September 7, 2026; and
WHEREAS, the Corpay contract was solicited through OMNIA Partners Cooperative and allows the
City to set rules for how the card can be used, how often and when, giving the City flexible control
limits; and
WHEREAS, Corpay also utilizes and integrates with the existing Fleet Management solution FASTER
and the Fleet Telematic system, Samsars, with extra tracking capabilities that will result in streamlined
operations and organization for the City’s Fleet, and will help the Fleet Division obtain more precise,
thorough and accurate information to track the fuel usage for each individual vehicle in real time.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
FAYETTEVILLE, ARKANSAS:
Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Mayor Rawn to
sign a contract with Corpay Technologies Operating Company, LLC, pursuant to an OMNIA
cooperative purchasing contract, to enable the City to participate in a fuel card program through June 30,
2029, and any future renewals.
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
City of Fayetteville Staff Review Form
2026-2574
Item ID
8/18/2026
City Council Meeting Date - Agenda Item Only
N/A for Non-Agenda Item
Amanda Beilfuss 7/29/2026 PURCHASING (160)
Submitted By Submitted Date Division / Department
Action Recommendation:
A resolution for approval of a credit application and for the use of Corpay Technologies Operating Company, LLC
(Fuelman) for Fleet fuel card services within the approved operating budget, utilizing OMNIA cooperative
purchasing contract #R260401, through June 30, 2029 and any future renewals.
Budget Impact:
Various Various
Account Number Fund
Various N/A
Project Number Project Title
Budgeted Item?No Total Amended Budget
Expenses (Actual+Encum)
Available Budget $-
Does item have a direct cost?No Item Cost
Is a Budget Adjustment attached?No Budget Adjustment $-
$182.00 Remaining Budget $-
V20221130
Purchase Order Number:Previous Ordinance or Resolution #
Change Order Number:Approval Date:
Original Contract Number:
Comments:
8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
CUSTOMER INFORMATION (Required) Fax or Email Completed Application to:
Company or Other Governmental Entity’s Full Legal Name
City of Fayetteville
Type of Business Years in Business Under Current Owner
Government
Subsidiary or DBA
N/A
Main Phone #
479-575-8256
Street Address (No PO Boxes)
113 W. Mountain St.
Cell Phone #
N/A
Street Address 2 Fax #
City State ZIP
Fayetteville AR 72701
Federal ID # Tax Exempt #
71-6018462 N/A
Is Billing Address Different than Business Address? Yes No # of Vehicles Monthly Fuel Spend
Billing Address (If Different Than Above) # of Full Time Employees
Billing Address 2 Security Code (5 digit)
City State ZIP Email Address
purchasing@fayetteville-ar.gov
First Name Last Name
Molly Rawn
Title
Mayor
Type of Organization: Non-Profit Government
AUTHORIZED SIGNATURE Required (Representative acknowledges receiving fuel pricing and payment terms) Initial Here _______
Corpay Technologies Operating Company, LLC (“Corpay”) operates the Fuelman Fleet Card program. By signing this application, I represent and warrant that I am duly authorized to request that a Fuelman Fleet Card account be created and the
card(s) issued on behalf of the company or other governmental entity identified above (“Applicant”). Corpay is hereby authorized to check Applicant’s credit worthiness, initially as well as from time to time, including but not limited to obtaining credit
report(s), contacting the Applicant’s bank, and obtaining trade references. Applicant acknowledges that this application is subject to approval and acceptance by Corpay. If this application is approved, then the Applicant’s Authorized Representative
listed above will be notified of the account’s available credit limit, the acceptable payment terms & method, and any applicable program fees. Program details including General Terms & Conditions for Use of Fleet Cards which were submitted as an
“Other Response Attachment” in Corpay’s response to Region 4 ESC RFP #26-04 and are also attached to this application, including Limitation of Liability provisions (herein “the Region 4 ESC/OMNIA Contract”), which Applicant hereby acknowledges
it has been provided access to such due diligence documents through OMNIA Partners website which are made available at the following web address: (https://www.omniapartners.com/publicsector), or have otherwise been provided by Corpay upon
Applicant’s written request. Applicant may also receive from Corpay from time-to-time a copy of its Fuelman Fleet Card Client Agreement Terms and Conditions, which is Corpay’s standard pamphlet style terms and conditions (herein “Terms &
Conditions Pamphlet”). The Terms & Conditions Pamphlet is not intended to supersede the OMNIA Contract, however there may be items covered in the Terms & Conditions Pamphlet which are not specifically addressed in the Region 4 ESC/OMNIA
Contract. In the event of a conflict between the Region 4 ESC/OMNIA Contract and the Terms & Conditions Pamphlet, the terms and conditions of the Region 4 ESC/OMNIA Contract shall control. Applicant acknowledges that the fleet card program
is not a revolving credit account and that any purchases made during the billing cycle are due and payable in full, including any applicable fees, upon receipt of the billing statement. If the Applicant’s unpaid balance ever meets or exceeds the
established credit limit, the account may be suspended immediately and the Applicant’s credit history may be reported to credit reporting agencies. Applicant’s acceptance, signing, in whatever form, or use of any of the cards provided to the Applicant
will constitute acceptance of the terms and conditions contained in this application and the account agreement. Applicant agrees that any liability arising or resulting from the misuse, unauthorized or fraudulent use, loss or theft of any of the cards
issued to the company’s account shall be fully borne, assumed and paid by the Applicant. If Corpay uses an attorney or collection agency to collect an unpaid overdue amount, the Applicant agrees to pay reasonable attorney and/or collection fees.
Applicant agrees that the account and cards are for business/commercial use only and are never to be used for either personal or household purposes, and Applicant agrees that use of the cards for any consumer and/or household purposes shall be
grounds for immediate termination of the Applicant’s account. Corpay complies with Section 326 of the USA Patriot Act, which mandates that Corpay verify certain information about the Applicant and/or Applicant owner, as may be applicable from
time to time, while processing this account application and during any future operation of an account.
FUELMAN® is a registered trademark of Corpay Technologies Operating Company, LLC.
I Agree to the Terms of this Application (Please check box) I do not want to consider other card programs
Print Name (Authorized Representative) Signature (Authorized Representative)
Molly Rawn
Title
Mayor
Date
Telephone #
479-575-8256
BUSINESS OWNER/ACCOUNT PRINCIPAL Required for all Proprietorships, Partnerships or any other business/organization less than two
years old or having fewer than five (5) employees.
Each principal (“Principal”) for this Account, if any, is personally and unconditionally, jointly and severally liable with Applicant, as principal and not as surety or guarantor, for the payment and performance when due of all obligations owed on the
Account, regardless of who made purchases using the Cards, and the Principal agrees to pay such amounts according to the terms of this Agreement. Principal is responsible under this Agreement for all use of all of the Cards issued on the Account
to the fullest extent permitted by law. This constitutes Principal’s agreement, individually, regarding the provisions under “AUTHORIZED SIGNATORY” above, including without limitation checking and reporting your credit and confirming your identity.
Principal First Name Middle Initial Last Name Principal Signature
Principal Street Address (No PO Boxes) Social Security # Date of Birth
Principal Street Address 2 Home Phone # -or-Cell Phone #
City State ZIP
**OFFICE USE ONLY**
Market: Rep ID: Rep Name: V 02-03-2026
APPLICATION FOR FLEET CARD ACCOUNT For OMNIA Partners participating Public Agencies using
the Region 4 ESC Master Agreement No. R260401 for
8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
TERMS DEFINITION PAYMENT METHOD
BILLING CYCLE: Weekly Bi-Weekly Calendar Monthly FM Monthly CHECK EFT
CHECK TERMS: NET 10 NET 14 NET 21 NET 30 EFT TERMS: NET 4 NET 7 NET 10
NET 14 NET 21
Mark (X) for
the desired
BF /
Terms
Billing Frequency /
Payment Terms
Applicable Billing
Terms Group for
Mark (X) for
the desired
BF /
Terms
Billing Frequency /
Payment Terms
Applicable Billing
Terms Group for
GROUP 1
(Shorter Terms)
GROUP 2
(Medium Terms)
WN7 Weekly Net 7 (EFT) MN7 Monthly Net 7 (EFT)
BWN4 Bi-Weekly Net 4 (EFT) WN21 Weekly Net 21
WN10 Weekly Net 10 MN10 Monthly Net 10
BWN7 Bi-Weekly Net 7 (EFT) BWN21 Bi-Weekly Net 21
BWN10 Bi-Weekly Net 10 MN14 Monthly Net 14
WN14 Weekly Net 14 WN30 Weekly Net 30
MN4 Monthly Net 4 (EFT) MN21 Monthly Net 21 GROUP 3 (Longer
Terms) * NOTE: Where “EFT” is indicated above, EFT is a mandatory payment method BWN30 Bi-Weekly Net 30
and the applicant MUST submit an EFT Enrollment Form with the Application. MN30 Monthly Net 30
EFT enrollment rules specify: If Weekly, must be Net 7 days or less, if Bi-Weekly, must be Net 14 days or less, if Monthly, must be Net 25 days or less.
PRICING SELECTION (Select Option 1 or Option 2, not both):
OPTION 1 - OPIS BASED COST-PLUS PRICING AT
PREFERRED NETWORK LOCATIONS OFF-SITE PRICING (Cost-plus Markups Per Gallon)
Check the Desired Billing Terms
1 Billing Terms Group1 Unleaded Mid-Grade Premium Diesel
GROUP 1 $0.140 $0.210 $0.240 $0.240
GROUP 2 $0.150 $0.220 $0.250 $0.250
GROUP 3 $0.170 $0.240 $0.270 $0.270
OPTION 1 (Continued) – Alternative Fuels that shall
always be priced based on Retail Price with Discounts OFF-SITE PRICING ALT. FUELS (Retail Minus Discounts Per Gallon)
Check the Desired Billing Terms
Group & Price that Shall Apply1
Billing Terms Group1
High Ethanol
Blends
High Biodiesel Blends
(B5 or Higher Blends) DEF
Dispensed
CNG or LNG
(Propane)
GROUP 1 -$0.040 -$0.060 -$0.030 -$0.010
GROUP 2 -$0.030 -$0.050 -$0.020 -$0.000
GROUP 3 -$0.010 -$0.030 -$0.000 -$0.000
OPTION 2 - RETAIL BASED PRICING WITH
DISCOUNTS PER GALLON AT PREFERRED NETWORK OFF-SITE PRICING (Retail Minus Discounts Per Gallon)
Check the Desired Billing Terms
1 Billing Terms Group1
All Gasoline
Products incl. High
All Diesel incl. High
Biodiesel Blends DEF
Dispensed
CNG or
LNG
GROUP 1 -$0.070 -$0.100 -$0.040 -$0.010
GROUP 2 -$0.060 -$0.090 -$0.030 -$0.000
GROUP 3 -$0.040 -$0.070 -$0.010 -$0.000
1 See the Billing Terms Group Definitions table above, Check the applicable Billing Terms Group you have chosen based on your Billing Terms selection.
SERVICES: OFF-SITE RETAIL TAX EXEMPT
OPTIONAL REPORTS: Optional Reports delivered via Web (online system logon) unless special requested by Email
Check or Mark (X)
for the desired
Optional
Report
Check or Mark (X)
for the desired
Optional
Report
TRN85
Electronic Transaction File, check below
for frequency, Email Delivery, & Contact:
REPORT DELIVERY METHOD (Reports at Billing): MAIL - $9.95 FAX - $4.95 EMAIL (no charge) WEB (no charge)
REPORT/STATEMENT DELIVERY INFORMATION:
Name: Ross Jackson Name: Kenny Fitch
Email: rjackson@fayetteville-ar.gov Email: kfitch@fayetteville-ar.gov
Phone #: 479-444-3495 Phone #: 479-575-8256
Terms & Conditions of the Region 4 ESC/OMNIA Partners contract # R260401 apply. I fully understand and accept the terms of this program.
Name: Molly Rawn Mayor
Signature: Date:
**OFFICE USE ONLY**
Market: Rep ID: Rep Name: V.02-17-2026
(Attach EFT Authorization Form*)
BILLING TERMS DEFINITION Select the desired BF/PT in table below, subject to Corpay credit approval)
8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
V 02-18-2026
ATTACHMENT A
To Fuelman Fleet Credit Card Application
Applicable to OMNIA Partners Participating Public Agencies using the
Region 4 ESC Master Agreement No. R260401 for Fuel Card Services
Extended Network Pricing Definitions and Never Below Corpay’s Cost Plus Minimum Margin
Per Corpay’s RFP response (Response Attachment 18 - Pricing, Section 1 defining Fuelman Card or Corpay Select Card
pricing) in the Region 4 ESC contract #R260401, a copy of applicable sup-paragraph 3 within this section is provided
below which defines certain merchants that are considered “Extended Network”. Extended Network locations are
excluded from OPIS-based, cost-plus pricing and pricing shall be based on Retail Price. Discounts apply at
certain locations or for certain fuel types as explained below. Additionally, a copy of section 9 of the RFP response,
which explains a pricing exception in the contract for Never Below Corpay’s Cost plus Minimum Margin.
3. PRICING AT EXTENDED NETWORK LOCATIONS
The current list of merchants (subject to future change) with applicable Extended Network Pricing includes:
3.1. Extended Network (No Discount or surcharge applies, subject to Exceptions Noted)
At the following chains or brands that offer chain-wide or brand-wide acceptance, Participating Agencies will be charged
based on the station’s Retail Price and in the case of ARCO, Retail Price plus the quoted per gallon rate. For certain
states where Participating Agencies have their address, we define exceptions that shall apply.
ARCO brand-wide acceptance stations at posted Retail Price plus $0.05 per gallon.
Buc-ee’s locations at posted Retail Price.
Chevron/Texaco1 brand-wide acceptance stations at posted Retail Price.
1 For Participating Agencies that have their address in the States of California, Oregon or Washington,
Corpay agrees to provide a discount equaling $0.02 (2 cents) per gallon on all fuel types at
Chevron/Texaco brand-wide acceptance locations. Discounts to be applied at the transaction level in
reporting, not as a rebate.
Sinclair2 brand-wide acceptance stations at posted Retail Price.
2 For Participating Agencies that have their address in the State of Utah, Corpay agrees to provide a
discount equaling $0.04 (4 cents) per gallon on all gasoline products, $0.05 (5 cents) per gallon on all
diesel fuel products, at Sinclair brand-wide acceptance locations. Alternative/Evolving fuel types at Sinclair
locations as follows: CNG/LNG - no discount, DEF Dispensed - $0.02 (2 cents) per gallon. All discounts to
be applied at the transaction level in reporting, not as a rebate.
3.2. Extended Network - Chains or Brands where a 3 cents Discount Shall Apply
At the following chains or brands that offer chain-wide or brand-wide acceptance, participating agencies will be charged
based on the station’s Retail Price, minus a discount equaling $0.03 (3 cents) per gallon on all fuel types.
Casey’s
CENEX
Exxon/Mobil brand-wide acceptance locations
Maverik/Kum & Go
Murphy USA/Murphy Express
OnCue
QuikTrip (QT)
Sams Club
Sheetz
Walmart
Wawa
3.3 Extended Network (Major Truck Stops where 8 cents discount on Diesel Only applies)
At the following major truck stop chains, Diesel Fuel shall always be priced based on the credit Retail Price for diesel
minus a discount equaling $0.08 (8 cents) per gallon. Gasoline, DEF Dispensed, CNG, or LNG shall be priced based
on the station’s Retail Price with no discount.
Love’s Country Store / Travel Stop Locations
Pilot or Flying J Travel Center Stations, Pilot Convenience Stores, or Pilot unattended card lock stations
TravelCenters of America (TA) or Petro Travel Centers
9. Never Below Corpay’s Cost Plus Minimum Margin
Corpay reserves the right to never bill Customer for any purchase at a price below Corpay’s cost to settle with the
Merchant plus a minimum margin to Corpay equaling $0.03 (3 cents) per gallon and in the event the Customer’s price
(including all merchant taxes before exemption) calculates to be below Corpay’s cost to settle with the Merchant,
Corpay’s cost plus a minimum margin to Corpay equaling $0.03 (3 cents) shall apply.
NOTE: Optional services: Fuelman Maintenance powered by CarAdvise; and Fraud Protector Program require signing
separate Addendum with Terms & Conditions.
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
V 02-18-2026
Corpay’s General Terms & Conditions for Use of Fuelman Fleet Cards
Applicable to OMNIA Partners Participating Public Agencies using the Region 4 ESC
Master Agreement No. R260401 for Fuel Card Services
Summary of Rates, Fees, and Other Costs
1.1 Security, Loss, Theft, or Unauthorized Use of Card.
1.1.1 General Security. Each fuel card (“Card”) can be programmed to only allow Fuel or both Fuel &
Maintenance services such as oil changes, vehicle washes, etc. Typically, each transaction is authorized with the
Card number, product code, quantity and driver’s Driver ID across the proprietary Fuelman network to ensure that
the purchase is authorized and limited to the product and quantity (e.g. gallons of Fuel or dollars of Maintenance)
that have been pre-approved. This system also helps prevent unauthorized Driver IDs and stolen Cards from being
used to make purchases. The product and quantity controls are subject to each merchant location’s POS
Authorization Limitations described herein.
1.1.2 Corpay’s Liability. In the event an unauthorized transaction occurs, subject to the limitations and
Customer responsibilities explained in this Section 1.1 and in the event that Customer’s account (the “Account”)
has been issued fewer than ten (10) Cards, Corpay will assume full responsibility for those purchases which occur
so long as Customer has complied with all its respective obligations and/or responsibilities set forth under Sections
1.1.3 and 1.1.4 included herein. If the Account has been issued ten (10) or more Cards, Customer assumes all
liability and responsibility for unauthorized transactions and/or Account activity.
1.1.3 Customer’s Responsibility. It is the responsibility of Customer to ensure proper security controls are kept
in place to protect the Cards and Driver IDs and that only authorized employees or agents of Customer use them
to make purchases. It is also the Customer’s responsibility to lock any inactive, misplaced, or stolen Cards and
Driver IDs immediately. Corpay is not responsible for fraudulent transactions made on unlocked Cards with valid
Driver IDs. Customer should use the online account application to lock Cards and Driver IDs instantly. Alternatively,
the Customer can contact Corpay Customer Service during regular business hours via fax or email with the
requested change, in which case Corpay will make the requested changes within 24 hours and assume
responsibility for any unauthorized purchases at that point. All transactions in which a valid/unlocked Card number
was used in conjunction with a valid/active Driver ID will be considered to be authorized transactions in which
Customer is fully responsible for payment. It is also the Customer’s responsibility to review the standard fleet
management reports and optional electronic mail or email exception alerts to identify potential purchasing
discrepancies. Customer should instruct its Cardholders to keep any record of their Driver ID separate from the
vehicle’s Card.
1.1.4 Lost or Stolen Cards. Customer shall report all lost or stolen Cards to Corpay immediately via phone call
or email to Corpay’s Customer Service department identifying the Card number and such other details concerning
the loss or theft of the Cards as are known by Customer. Customer shall be liable for all transactions made by lost
or stolen Cards until Corpay receives Customer’s written notice of such lost or stolen Cards. Customer and
Guarantor(s) agree to and acknowledge full liability for any losses resulting from any failure to promptly report the
loss and/or theft of Card(s) in accordance with the terms hereof.
1.1.5 Terminated Drivers. It is the Customer’s responsibility to lock a terminated driver’s Driver ID as explained
herein.
Important Note: Please review all of these materials so that you, Customer, are fully informed about your
terms and conditions. Please select “AGREE” to certify your agreement to each specific Program Fee(s)
included in the table below that you, Customer, are agreeing to pay Corpay Technologies Operating
Company, LLC (“Corpay”) in connection with your execution of this Agreement.
AGREE Category Fee Amount When Charged
Expedited Next Day
Air Card Shipping
Fees
Up to $35 per Card.
Charged when Customer requests
additional cards and requires expedited
next day shipping. Fee is generally
assessed on a per package shipped
basis.
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
V 02-18-2026
1.1.6 Merchant Limitations. The personnel (if any) at a Merchant Location are not the agents or employees of
Corpay and Corpay shall not be responsible for the products or services rendered by any of the Merchants or any
other liability or damage which arises from the action or negligence of the personnel of any of the Merchants, their
agents or their employees.
1.1.7 POS Authorization Limitations. Authorization controls are provided as a convenience to the Customer
and are not guaranteed to prevent unauthorized purchases. Specifically, depending on the particular point-of-sale
(POS) equipment and Fuel dispenser controls being used by a particular Merchant Location, the product type and
spending limit may not be enforceable prior to completing the transaction. In these situations, the transaction will
still be considered to be authorized, but will be identified as an exception on the Customer’s standard fleet
management report and reported via email if desired by Customer.
1.1.8 Claims. All claims for defective Fuel or Maintenance must be made to the Merchant operating the Merchant
Location where such Fuel or Maintenance was purchased. Any claim for defective Fuel or Maintenance is waived
by Client unless made in writing to Merchant, with a copy to Corpay, within fifteen (15) days from the date of the
purchase of the alleged defective Fuel or Maintenance giving rise to the claim.
1.2 Account Administration and Card Issuance.
1.2.1 Credit Limit. Upon receipt of notice of award of SOLICITATION/contract and signed credit applications
from Customer, Corpay will establish an aggregate spending limit for all the Cards issued to Customer under the
Account(s) (the “Credit Limit”) based on Corpay’s evaluation of the Customer’s creditworthiness. The initial Credit
Limit may have already been established (applicable to existing older accounts already using Fuelman cards issued
by Corpay). Corpay reserves the right to increase or decrease this Credit Limit at any time with or without providing
notice to Customer. So long as sufficient creditworthiness exists, the intention shall be to have sufficient credit limit
to meet the anticipated purchasing projections or purchasing history/activity of the Customer under the billing
frequency and terms provided in the relevant RFP response. The total outstanding balance (the amount Customer
owes Corpay) appears as the “Amount Due” or “Total Amount Due” on Customer’s statement. This is not a revolving
credit account. The Amount Due/Total Amount Due shown on each Account statement is due and payable by the
due date (“Due Date”) shown on the statement. The Amount Due/Total Amount Due includes current transactions,
applicable service fees, amounts past due, late fees, charges for returned checks and other applicable charges.
Corpay can accept late or partial payments, as well as payments that reflect “paid in full” or other restrictive
endorsements, without losing any of Corpay’s rights under these terms and conditions.
1.2.2 Administration of Cards. Customer shall be solely responsible for the use, maintenance, administration,
and security of the Cards and Driver IDs within Customer’s business, including, but not limited to, distributing Cards
to, and collecting Cards from, its employees and agents. Notwithstanding any other provision in these terms and
conditions, Customer is responsible for any loss and/or misuse of Cards by its employees and/or agents. See
Section 1.1 for more information regarding Customer responsibilities.
1.2.3 Account Administration (Contact Persons). To ensure effective communication between your Fleet
Manager or Card Program Administrator, your Accounts Payable Representative, and Corpay, Customer will
provide the requested contact information for both an authorized Fleet Contact and Billing Contact. Up-to-date
information about your account will be communicated through these designated persons. For example, if your
account becomes past due or exceeds the assigned credit limit, or if we have identified suspected fraudulent activity,
the listed individuals on the account may be notified electronically to avoid a disruption in service or to confirm
whether suspected fraudulent purchases identified are legitimate. Customer shall contact Corpay’s Fuelman
customer service department or your account manager if any of this information changes for the authorized Fleet
Contact or Billing Contact person.
1.2.4 Cancellation of Cards. If, at any time, for any reason, Customer desires to cancel any particular Card,
but not the Account, Customer’s Representative must notify Corpay via the online application or in writing of such
cancellation. Customer’s liability for purchases made using the canceled Card shall when Corpay receives written
notice of such Card cancellation. The on-line application allows customer to instantly cancel (lock) cards.
1.2.5 Suspension of Cards. Corpay, at its sole discretion, may suspend or terminate the use of any Card at
any time for any reason, including, but not limited to, inactivity, unusual activity, or suspected loss, theft, fraud, or
in compliance with the USA Patriot Act. However, nothing in these terms and conditions shall obligate Corpay to
monitor the use of any Card, and, as described in these terms and conditions, Customer is solely responsible for
the use of any outstanding Cards.
1.2.6 Suspension of Account. Corpay, reserves the right to suspend or terminate the use of an Account due
to substantial change in creditworthiness, late payment (excessive days beyond terms), aggregate outstanding
balance owing on the Account (outstanding Account balance and unbilled transactions) over the Credit Limit or in
compliance with the USA Patriot Act.
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
V 02-18-2026
1.3 Limitation of Liability; Force Majeure; Modifications; Miscellaneous.
1.3.1 Limitation of Liability. THE PARTIES WILL HAVE NO LIABILITY FOR INDIRECT, SPECIAL,
CONSEQUENTIAL, PUNITIVE, OR INCIDENTAL DAMAGES OF ANY KIND, INCLUDING CLAIMS FOR LOSS
OF PROFITS, WHETHER RESULTING DIRECTLY OR INDIRECTLY TO CUSTOMER, CORPAY, GUARANTOR,
OR THIRD PARTIES, AND WHETHER ARISING IN CONTRACT, TORT, OR OTHERWISE, EVEN IF SUCH
DAMAGES WERE FORESEEABLE OR RESULT FROM A BREACH OF THESE TERMS AND CONDITIONS. IN
THE EVENT A COURT IN A FINAL, NON-APPEALABLE AWARD FINDS CORPAY OR CUSTOMER LIABLE FOR
ANY DIRECT DAMAGES, CORPAY OR CUSTOMER’S LIABILITY IN THE AGGREGATE FOR SUCH DIRECT
DAMAGES WILL NOT EXCEED THE AMOUNT PAID OR PAYABLE BY CUSTOMER TO CORPAY FOR THE
THREE (3) MONTHS PRECEDING THE DATE ON WHICH THE CLAIM AROSE.
1.3.2 Force Majeure. Corpay shall not be liable for failure to perform when such failure is occasioned or caused
by an act of God or other circumstances beyond its control.
1.3.3. Modifications. Unless otherwise set forth herein, any material amendments, modifications, and/or
changes to these specific “Corpay’s General Terms & Conditions for Use of Fleet Cards Applicable to OMNIA
Partners Participating Public Agencies using the Region 4 ESC” may only be effectuated through a written
agreement or instrument which has been duly executed by both Corpay and Customer.
1.3.4. Miscellaneous. These terms and conditions: (a) will be governed by the laws of the state where the
Customer is domiciled, without regard to its conflicts of laws principles, (b) may be assigned by either party only
upon the prior written approval of the other party which will not be unreasonably withheld conditioned or delayed;
(c) will be binding on the parties’ successors and permitted assigns; (d) together with the RFP response, as
applicable, constitute the entire agreement of the parties with respect to its subject matter; supersedes all prior
agreements and understandings, oral or written, of the parties with respect to this subject matter; and except as
expressly set forth in these terms and conditions, may only be modified by a writing signed by Corpay and Customer
or by Customer’s acceptance of additional or substitute terms delivered to Customer by Corpay via phone, website,
email, text, or such other means as may be elected by Corpay; and (e) do not create any partnership, agency
relationship, or joint venture. If any provision of these terms and conditions is found to be fully or partially invalid or
unenforceable, it will be enforced to the extent permitted by law, and the remainder will not be affected. No waiver
of any provision of these terms and conditions will constitute a waiver of the same provision on another occasion.
The rights and obligations of these terms and conditions which by their nature are intended to survive expiration or
termination will so survive. Customer and Corpay agree that any electronic signatures used in connection with
Corpay’s General Terms & Conditions are intended to authenticate this writing and to have the same force and
effect as a manual signature.
ACCEPTED AND AGREED:
Customer Name: City of Fayetteville
Signature:
Printed Name: Molly Rawn, Mayor
Date: 8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
Corpay Technologies Operating Company, LLC
109 Northpark Blvd, Ste 500
Covington, LA 70433
MARKETER_______________ BG ACCT# _______________
FEIN: 20-2008209 Tax Exempt Fax: 866-224-3835
Tax Exempt email: Taxdeptqueuecs@Corpay.com 2026
Federal Excise Tax Exemption Certificate Request for Credit/Refund
For use by States, Territories or political subdivisions thereof, the District of Columbia and
Non-Profit Education Organizations to support vendor/credit card issuers claim for a credit, refund or payment
under Section 6416(a)(4)(B) (gas) AND/OR 6427(l)(5)(D) (diesel) of the Internal Revenue Code
The undersigned ultimate purchaser (“Buyer”) hereby certifies under penalties of perjury that he/she is:
_______________________________________________________________________
(Name & Title of officer or agent)
of ___________________________________________________ of ________________________________________________
(Department, Bureau or Commission or Organization – Legal Name)(City)(State)
and that he/she is authorized to execute this certificate and that the article or articles specified below or for the period
indicated below were purchased and Buyer is eligible for a tax credit or refund by virtue of being (classification must be
checked and applicable information furnished):
Buyer to which this certificate relates is (check one):
______ 1. A state, any political subdivision thereof, or the District of Columbia
______ 2. A non-profit educational organization, in section 170(b)(1)(A)(ii) of the IRS code, which normally maintains a
regular faculty and curriculum and normally has a regularly enrolled body of pupils or students in attendance
at the place where its educational activities are regularly carried on
(IF YOU CHECKED #2, PLEASE PROVIDE COPY OF IRS DETERMINATION LETTER)
Date of Internal Revenue Service Ruling Letter if #2 above checked ___________________________.
The Buyer will provide a new certificate to the vendor/credit card issuer if any information in this certificate changes.
The undersigned understands that the credit or refund of tax in the case of sales of articles covered under this exemption
certificate is limited to the sale of articles purchased for its exclusive use, and it is agreed that if articles purchased on
which credit or refund has been issued under this exemption certificate are used otherwise or are sold to employees or
others, such fact will be reported to the vendor/credit card issuer covered by this certificate. It is understood that the
fraudulent use of this certificate may subject the guilty parties to a maximum fine of $10,000 and imprisonment for not
more than 5 years. If the articles sold hereunder are subjected to Federal excise taxes, the Buyer agrees that it shall pay all
tax, penalties and interest or reimburse the credit card issuer for such amounts assessed by the Federal Government.
Buyer understands that by signing this certificate, Buyer gives up its right to claim a credit or refund for the articles for
which this certificate relates. The buyer further certifies that buyer has not and will not file for credit or refund for the
articles for which this certificate relates. The buyer consents to the allowance of a credit or refund of any taxes paid.
Blanks must be filled in:
Purchases made during the period of 01/01/2026 through 12 /31/2026 (period not to exceed one year)
OR Purchaser’s Order No. _________________
__________________________________________________ _______________________________________________
(Signature of Officer or Agent)(Date Signed)
___ ___ - ___ ___ ___ ___ ___ ___ ___ _______________________________________________
(FEDERAL EMPLOYER IDENTIFICATION NUMBER/FEIN/EIN)(Address of Buyer)
**Not to be confused with your State ID number**
Business phone number _______________________________________Email Address of person completing form:
Business fax number ____________________________________________________________________________________________________
NOTES: *IF YOU ARE SALES TAX EXEMPT, PLEASE SUBMIT A COPY OF YOUR SALES TAX EXEMPT CERTIFICATE FOR REVIEW
*NO EXEMPTION FOR $.007/GALLON FEDERAL UNDERGROUND STORAGE (LUST), SUPERFUND, AND OIL SPILL FEES
Molly Rawn, Mayor
City Fayetteville AR
X
7 1 6 0 1 8 4 6 2 113 W. Mountain St., Fayetteville, AR 72701
479-575-8256
479-575-8257 abeilfuss@fayetteville-ar.gov
8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
Corpay Technologies Operating Company, LLC
109 Northpark Blvd, Ste 500
Covington, LA 70433
MARKETER_______________ BG ACCT# _______________
FEIN: 20-2008209 Tax Exempt Fax: 866-224-3835
Tax Exempt email: Taxdeptqueuecs@Corpay.com 2027
Federal Excise Tax Exemption Certificate Request for Credit/Refund
For use by States, Territories or political subdivisions thereof, the District of Columbia and
Non-Profit Education Organizations to support vendor/credit card issuers claim for a credit, refund or payment
under Section 6416(a)(4)(B) (gas) AND/OR 6427(l)(5)(D) (diesel) of the Internal Revenue Code
The undersigned ultimate purchaser (“Buyer”) hereby certifies under penalties of perjury that he/she is:
_______________________________________________________________________
(Name & Title of officer or agent)
of ___________________________________________________ of ________________________________________________
(Department, Bureau or Commission or Organization – Legal Name)(City)(State)
and that he/she is authorized to execute this certificate and that the article or articles specified below or for the period
indicated below were purchased and Buyer is eligible for a tax credit or refund by virtue of being (classification must be
checked and applicable information furnished):
Buyer to which this certificate relates is (check one):
______ 1. A state, any political subdivision thereof, or the District of Columbia
______ 2. A non-profit educational organization, in section 170(b)(1)(A)(ii) of the IRS code, which normally maintains a
regular faculty and curriculum and normally has a regularly enrolled body of pupils or students in attendance
at the place where its educational activities are regularly carried on
(IF YOU CHECKED #2, PLEASE PROVIDE COPY OF IRS DETERMINATION LETTER)
Date of Internal Revenue Service Ruling Letter if #2 above checked ___________________________.
The Buyer will provide a new certificate to the vendor/credit card issuer if any information in this certificate changes.
The undersigned understands that the credit or refund of tax in the case of sales of articles covered under this exemption
certificate is limited to the sale of articles purchased for its exclusive use, and it is agreed that if articles purchased on
which credit or refund has been issued under this exemption certificate are used otherwise or are sold to employees or
others, such fact will be reported to the vendor/credit card issuer covered by this certificate. It is understood that the
fraudulent use of this certificate may subject the guilty parties to a maximum fine of $10,000 and imprisonment for not
more than 5 years. If the articles sold hereunder are subjected to Federal excise taxes, the Buyer agrees that it shall pay all
tax, penalties and interest or reimburse the credit card issuer for such amounts assessed by the Federal Government.
Buyer understands that by signing this certificate, Buyer gives up its right to claim a credit or refund for the articles for
which this certificate relates. The buyer further certifies that buyer has not and will not file for credit or refund for the
articles for which this certificate relates. The buyer consents to the allowance of a credit or refund of any taxes paid.
Blanks must be filled in:
Purchases made during the period of 01/01/2027 through 12 /31/2027 (period not to exceed one year)
OR Purchaser’s Order No. _________________
__________________________________________________ _______________________________________________
(Signature of Officer or Agent)(Date Signed)
___ ___ - ___ ___ ___ ___ ___ ___ ___ _______________________________________________
(FEDERAL EMPLOYER IDENTIFICATION NUMBER/FEIN/EIN)(Address of Buyer)
**Not to be confused with your State ID number**
Business phone number _______________________________________Email Address of person completing form:
Business fax number ____________________________________________________________________________________________________
NOTES: *IF YOU ARE SALES TAX EXEMPT, PLEASE SUBMIT A COPY OF YOUR SALES TAX EXEMPT CERTIFICATE FOR REVIEW
*NO EXEMPTION FOR $.005/GALLON FEDERAL UNDERGROUND STORAGE (LUST), SUPERFUND, AND OIL SPILL FEES
Molly Rawn, Mayor
City Fayetteville AR
X
7 1 6 0 1 8 4 6 2 113 W. Mountain St., Fayetteville, AR 72701
479-575-8256
479-575-8257 abeilfuss@fayetteville-ar.gov
8/18/2026
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
Region 4 Education Service Center •7145WestTidwell Road • Houston,Texas 77092-2096
Phone: 713.462.7708 •Fax: 713.744.6514 •esc4.net
RodneyWatson, PhD, Executive Director
June 23, 2026
Joseph (Joey) Kendrick
President, Fleet Mastercard
Corpay Technologies Operating Company, LLC
3280 Peachtree Road, Suite 2400
Atlanta, GA 30305
Joseph.kendrick@corpay.com
Re: Award of Contract # R260401
Dear Joseph (Joey) Kendrick:
Per official action taken by the Board of Directors of Region 4 Education Service Center
on June 23, 2026, we are pleased to announce that Corpay Technologies Operating
Company, LLC has been awarded a three (3) year contract, contingent upon successful
negotiations, if needed,for the following, based on the online proposal RFP# 26-04
openedon February 19, 2026:
Commodity/Service Supplier
Fuel Card Services Corpay Technologies Operating Company, LLC
This contract is effective July 1, 2026, and will expire on June30, 2029. As indicated
above, your contract number is R260401. This contract may be renewed annually for an
additional two (2) years if mutually agreed upon by Region 4 ESC and Corpay
Technologies Operating Company, LLC.
Your participation in the proposal process is appreciated and we look forward to a
successful partnership. Please feel free to provide copies of this letter to your sales
representative(s) to assist in their daily course of business.
If you have any questions, please contact our Procurement Department at 713-462-
7708 or questions@esc4.net.
Sincerely,
Enrique Kladis
ProcurementDirector
Docusign Envelope ID: 66505472-DB52-8DA2-81F6-E61308508C1A
TO: Molly Rawn, Mayor
THRU: Steve Dotson, Chief Financial Officer
FROM: Amanda Beilfuss, Procurement Director
DATE: Monday, August 24, 2026
SUBJECT: Application for second fuel card account and for EFT Payment
RECOMMENDATION:
Procurement recommends the signing of a second fuel card services application for Corpay
Technologies Operating Company, LLC (Fuelman), enabling the City to open a second fuel card
account off of OMNIA cooperative purchasing contract #R260401 and also signing the EFT
authorization form so payments on both accounts can be made via EFT.
BACKGROUND:
On August 18, 2026 via Resolution 183-26, the Fayetteville City Council authorized the City to
submit an application/agreement with Corpay Technologies (Fuelman) for the City to participate
in new fuel card program, to replace the existing program.
DISCUSSION:
Signing this second application will enable the City to open a second account with Corpay
Technologies (Fuelman), which is needed to maintain continued use of a second account for the
Fayetteville Police Department, due to the needs of the Department. Corpay requires the City to
complete a new signed application in order to open the second account under the OMNIA
contract.
Signing the electronic funds transfer authorization form will enable the City to make payments
electronically with Corpay, which also enables the City to take advantage of bigger discount
pricing on the fuel purchases utilizing the new fuel cards.
BUDGET/STAFF IMPACT:
Fuel purchased under the new account is a budgeted expense.
Attachments:
Corpay Technologies (Fuelman) Application
EFT Authorization Form
Comments:
Purchase Order Number:
Change Order Number:
Previous Ordinance or Resolution #183-26
Approval Date:
Original Contract Number:
Various
Budget Impact:
N/A
VariousVarious
City of Fayetteville Staff Review Form
2026-0830
N/A
Procurement recommends the signing of a second fuel card services application for Corpay Technologies Operating
Company, LLC (Fuelman), enabling the City to open a second fuel card account off of OMNIA cooperative
purchasing contract #R260401 and also signing the EFT authorization form so payments on both accounts can be
made via EFT.
N/A for Non-Agenda Item
Action Recommendation:
Amanda Beilfuss PURCHASING (160)
Division / Department
8/24/2026
Submitted Date
No
-$
V20221130
Budgeted Item?
Does item have a direct cost?
Is a Budget Adjustment attached?
Total Amended Budget
Expenses (Actual+Encum)
Item Cost
Budget Adjustment
Remaining Budget
No
No -$
-$
CUSTOMER INFORMATION (Required) Fax or Email Completed Application to:
Company or Other Governmental Entity’s Full Legal Name
City of Fayetteville
Type of Business Years in Business Under Current Owner
Government
Subsidiary or DBA Main Phone #
479-575-8256
Street Address (No PO Boxes)
113 W. Mountain St.
Cell Phone #
N/A
Street Address 2 Fax #
City State ZIP
Fayetteville AR 72701
Federal ID # Tax Exempt #
71-6018462 N/A
Is Billing Address Different than Business Address? Yes No # of Vehicles Monthly Fuel Spend
Billing Address (If Different Than Above) # of Full Time Employees
Billing Address 2 Security Code (5 digit)
City State ZIP Email Address
purchasing@fayetteville-ar.gov
First Name Last Name
Molly Rawn
Title
Mayor
Type of Organization: Non-Profit Government
AUTHORIZED SIGNATURE Required (Representative acknowledges receiving fuel pricing and payment terms) Initial Here _______
Corpay Technologies Operating Company, LLC (“Corpay”) operates the Fuelman Fleet Card program. By signing this application, I represent and warrant that I am duly authorized to request that a Fuelman Fleet Card account be created and the
card(s) issued on behalf of the company or other governmental entity identified above (“Applicant”). Corpay is hereby authorized to check Applicant’s credit worthiness, initially as well as from time to time, including but not limited to obtaining credit
report(s), contacting the Applicant’s bank, and obtaining trade references. Applicant acknowledges that this application is subject to approval and acceptance by Corpay. If this application is approved, then the Applicant’s Authorized Representative
listed above will be notified of the account’s available credit limit, the acceptable payment terms & method, and any applicable program fees. Program details including General Terms & Conditions for Use of Fleet Cards which were submitted as an
“Other Response Attachment” in Corpay’s response to Region 4 ESC RFP #26-04 and are also attached to this application, including Limitation of Liability provisions (herein “the Region 4 ESC/OMNIA Contract”), which Applicant hereby acknowledges
it has been provided access to such due diligence documents through OMNIA Partners website which are made available at the following web address: (https://www.omniapartners.com/publicsector), or have otherwise been provided by Corpay upon
Applicant’s written request. Applicant may also receive from Corpay from time-to-time a copy of its Fuelman Fleet Card Client Agreement Terms and Conditions, which is Corpay’s standard pamphlet style terms and conditions (herein “Terms &
Conditions Pamphlet”). The Terms & Conditions Pamphlet is not intended to supersede the OMNIA Contract, however there may be items covered in the Terms & Conditions Pamphlet which are not specifically addressed in the Region 4 ESC/OMNIA
Contract. In the event of a conflict between the Region 4 ESC/OMNIA Contract and the Terms & Conditions Pamphlet, the terms and conditions of the Region 4 ESC/OMNIA Contract shall control. Applicant acknowledges that the fleet card program
is not a revolving credit account and that any purchases made during the billing cycle are due and payable in full, including any applicable fees, upon receipt of the billing statement. If the Applicant’s unpaid balance ever meets or exceeds the
established credit limit, the account may be suspended immediately and the Applicant’s credit history may be reported to credit reporting agencies. Applicant’s acceptance, signing, in whatever form, or use of any of the cards provided to the Applicant
will constitute acceptance of the terms and conditions contained in this application and the account agreement. Applicant agrees that any liability arising or resulting from the misuse, unauthorized or fraudulent use, loss or theft of any of the cards
issued to the company’s account shall be fully borne, assumed and paid by the Applicant. If Corpay uses an attorney or collection agency to collect an unpaid overdue amount, the Applicant agrees to pay reasonable attorney and/or collection fees.
Applicant agrees that the account and cards are for business/commercial use only and are never to be used for either personal or household purposes, and Applicant agrees that use of the cards for any consumer and/or household purposes shall be
grounds for immediate termination of the Applicant’s account. Corpay complies with Section 326 of the USA Patriot Act, which mandates that Corpay verify certain information about the Applicant and/or Applicant owner, as may be applicable from
time to time, while processing this account application and during any future operation of an account.
FUELMAN® is a registered trademark of Corpay Technologies Operating Company, LLC.
I Agree to the Terms of this Application (Please check box) I do not want to consider other card programs
Print Name (Authorized Representative) Signature (Authorized Representative)
Molly Rawn
Title
Mayor
Date
Telephone #
479-575-8256
BUSINESS OWNER/ACCOUNT PRINCIPAL Required for all Proprietorships, Partnerships or any other business/organization less than two
years old or having fewer than five (5) employees.
Each principal (“Principal”) for this Account, if any, is personally and unconditionally, jointly and severally liable with Applicant, as principal and not as surety or guarantor, for the payment and performance when due of all obligations owed on the
Account, regardless of who made purchases using the Cards, and the Principal agrees to pay such amounts according to the terms of this Agreement. Principal is responsible under this Agreement for all use of all of the Cards issued on the Account
to the fullest extent permitted by law. This constitutes Principal’s agreement, individually, regarding the provisions under “AUTHORIZED SIGNATORY” above, including without limitation checking and reporting your credit and confirming your identity.
Principal First Name Middle Initial Last Name Principal Signature
Principal Street Address (No PO Boxes) Social Security # Date of Birth
Principal Street Address 2 Home Phone # -or-Cell Phone #
City State ZIP
**OFFICE USE ONLY**
Market: Rep ID: Rep Name: V 02-03-2026
APPLICATION FOR FLEET CARD ACCOUNT For OMNIA Partners participating Public Agencies using
the Region 4 ESC Master Agreement No. R260401 for
08/26/2026
Docusign Envelope ID: 94EF8487-C4A4-8AD3-81A9-D6F4812DA66D
TERMS DEFINITION PAYMENT METHOD
BILLING CYCLE: Weekly Bi-Weekly Calendar Monthly FM Monthly CHECK EFT
CHECK TERMS: NET 10 NET 14 NET 21 NET 30 EFT TERMS: NET 4 NET 7 NET 10
NET 14 NET 21
Mark (X) for
the desired
BF /
Terms
Billing Frequency /
Payment Terms
Applicable Billing
Terms Group for
Mark (X) for
the desired
BF /
Terms
Billing Frequency /
Payment Terms
Applicable Billing
Terms Group for
GROUP 1
(Shorter Terms)
GROUP 2
(Medium Terms)
WN7 Weekly Net 7 (EFT) MN7 Monthly Net 7 (EFT)
BWN4 Bi-Weekly Net 4 (EFT) WN21 Weekly Net 21
WN10 Weekly Net 10 MN10 Monthly Net 10
BWN7 Bi-Weekly Net 7 (EFT) BWN21 Bi-Weekly Net 21
BWN10 Bi-Weekly Net 10 MN14 Monthly Net 14
WN14 Weekly Net 14 WN30 Weekly Net 30
MN4 Monthly Net 4 (EFT) MN21 Monthly Net 21 GROUP 3 (Longer
Terms) * NOTE: Where “EFT” is indicated above, EFT is a mandatory payment method BWN30 Bi-Weekly Net 30
and the applicant MUST submit an EFT Enrollment Form with the Application. MN30 Monthly Net 30
EFT enrollment rules specify: If Weekly, must be Net 7 days or less, if Bi-Weekly, must be Net 14 days or less, if Monthly, must be Net 25 days or less.
PRICING SELECTION (Select Option 1 or Option 2, not both):
OPTION 1 - OPIS BASED COST-PLUS PRICING AT
PREFERRED NETWORK LOCATIONS OFF-SITE PRICING (Cost-plus Markups Per Gallon)
Check the Desired Billing Terms
1 Billing Terms Group1 Unleaded Mid-Grade Premium Diesel
GROUP 1 $0.140 $0.210 $0.240 $0.240
GROUP 2 $0.150 $0.220 $0.250 $0.250
GROUP 3 $0.170 $0.240 $0.270 $0.270
OPTION 1 (Continued) – Alternative Fuels that shall
always be priced based on Retail Price with Discounts OFF-SITE PRICING ALT. FUELS (Retail Minus Discounts Per Gallon)
Check the Desired Billing Terms
Group & Price that Shall Apply1
Billing Terms Group1
High Ethanol
Blends
High Biodiesel Blends
(B5 or Higher Blends) DEF
Dispensed
CNG or LNG
(Propane)
GROUP 1 -$0.040 -$0.060 -$0.030 -$0.010
GROUP 2 -$0.030 -$0.050 -$0.020 -$0.000
GROUP 3 -$0.010 -$0.030 -$0.000 -$0.000
OPTION 2 - RETAIL BASED PRICING WITH
DISCOUNTS PER GALLON AT PREFERRED NETWORK OFF-SITE PRICING (Retail Minus Discounts Per Gallon)
Check the Desired Billing Terms
1 Billing Terms Group1
All Gasoline
Products incl. High
All Diesel incl. High
Biodiesel Blends DEF
Dispensed
CNG or
LNG
GROUP 1 -$0.070 -$0.100 -$0.040 -$0.010
GROUP 2 -$0.060 -$0.090 -$0.030 -$0.000
GROUP 3 -$0.040 -$0.070 -$0.010 -$0.000
1 See the Billing Terms Group Definitions table above, Check the applicable Billing Terms Group you have chosen based on your Billing Terms selection.
SERVICES: OFF-SITE RETAIL TAX EXEMPT
OPTIONAL REPORTS: Optional Reports delivered via Web (online system logon) unless special requested by Email
Check or Mark (X)
for the desired
Optional
Report
Check or Mark (X)
for the desired
Optional
Report
TRN85
Electronic Transaction File, check below
for frequency, Email Delivery, & Contact:
REPORT DELIVERY METHOD (Reports at Billing): MAIL - $9.95 FAX - $4.95 EMAIL (no charge) WEB (no charge)
REPORT/STATEMENT DELIVERY INFORMATION:
Name: Willie Newman Name: Kenny Fitch
Email: wnewman@fayetteville-ar.gov Email: kfitch@fayetteville-ar.gov
Phone #: 479-587-3581 Phone #: 479-575-8256
Terms & Conditions of the Region 4 ESC/OMNIA Partners contract # R260401 apply. I fully understand and accept the terms of this program.
Name: Molly Rawn Mayor
Signature: Date:
**OFFICE USE ONLY**
Market: Rep ID: Rep Name: V.02-17-2026
(Attach EFT Authorization Form*)
BILLING TERMS DEFINITION Select the desired BF/PT in table below, subject to Corpay credit approval)
08/26/2026
Docusign Envelope ID: 94EF8487-C4A4-8AD3-81A9-D6F4812DA66D
V 02-18-2026
ATTACHMENT A
To Fuelman Fleet Credit Card Application
Applicable to OMNIA Partners Participating Public Agencies using the
Region 4 ESC Master Agreement No. R260401 for Fuel Card Services
Extended Network Pricing Definitions and Never Below Corpay’s Cost Plus Minimum Margin
Per Corpay’s RFP response (Response Attachment 18 - Pricing, Section 1 defining Fuelman Card or Corpay Select Card
pricing) in the Region 4 ESC contract #R260401, a copy of applicable sup-paragraph 3 within this section is provided
below which defines certain merchants that are considered “Extended Network”. Extended Network locations are
excluded from OPIS-based, cost-plus pricing and pricing shall be based on Retail Price. Discounts apply at
certain locations or for certain fuel types as explained below. Additionally, a copy of section 9 of the RFP response,
which explains a pricing exception in the contract for Never Below Corpay’s Cost plus Minimum Margin.
3. PRICING AT EXTENDED NETWORK LOCATIONS
The current list of merchants (subject to future change) with applicable Extended Network Pricing includes:
3.1. Extended Network (No Discount or surcharge applies, subject to Exceptions Noted)
At the following chains or brands that offer chain-wide or brand-wide acceptance, Participating Agencies will be charged
based on the station’s Retail Price and in the case of ARCO, Retail Price plus the quoted per gallon rate. For certain
states where Participating Agencies have their address, we define exceptions that shall apply.
ARCO brand-wide acceptance stations at posted Retail Price plus $0.05 per gallon.
Buc-ee’s locations at posted Retail Price.
Chevron/Texaco1 brand-wide acceptance stations at posted Retail Price.
1 For Participating Agencies that have their address in the States of California, Oregon or Washington,
Corpay agrees to provide a discount equaling $0.02 (2 cents) per gallon on all fuel types at
Chevron/Texaco brand-wide acceptance locations. Discounts to be applied at the transaction level in
reporting, not as a rebate.
Sinclair2 brand-wide acceptance stations at posted Retail Price.
2 For Participating Agencies that have their address in the State of Utah, Corpay agrees to provide a
discount equaling $0.04 (4 cents) per gallon on all gasoline products, $0.05 (5 cents) per gallon on all
diesel fuel products, at Sinclair brand-wide acceptance locations. Alternative/Evolving fuel types at Sinclair
locations as follows: CNG/LNG - no discount, DEF Dispensed - $0.02 (2 cents) per gallon. All discounts to
be applied at the transaction level in reporting, not as a rebate.
3.2. Extended Network - Chains or Brands where a 3 cents Discount Shall Apply
At the following chains or brands that offer chain-wide or brand-wide acceptance, participating agencies will be charged
based on the station’s Retail Price, minus a discount equaling $0.03 (3 cents) per gallon on all fuel types.
Casey’s
CENEX
Exxon/Mobil brand-wide acceptance locations
Maverik/Kum & Go
Murphy USA/Murphy Express
OnCue
QuikTrip (QT)
Sams Club
Sheetz
Walmart
Wawa
3.3 Extended Network (Major Truck Stops where 8 cents discount on Diesel Only applies)
At the following major truck stop chains, Diesel Fuel shall always be priced based on the credit Retail Price for diesel
minus a discount equaling $0.08 (8 cents) per gallon. Gasoline, DEF Dispensed, CNG, or LNG shall be priced based
on the station’s Retail Price with no discount.
Love’s Country Store / Travel Stop Locations
Pilot or Flying J Travel Center Stations, Pilot Convenience Stores, or Pilot unattended card lock stations
TravelCenters of America (TA) or Petro Travel Centers
9. Never Below Corpay’s Cost Plus Minimum Margin
Corpay reserves the right to never bill Customer for any purchase at a price below Corpay’s cost to settle with the
Merchant plus a minimum margin to Corpay equaling $0.03 (3 cents) per gallon and in the event the Customer’s price
(including all merchant taxes before exemption) calculates to be below Corpay’s cost to settle with the Merchant,
Corpay’s cost plus a minimum margin to Corpay equaling $0.03 (3 cents) shall apply.
NOTE: Optional services: Fuelman Maintenance powered by CarAdvise; and Fraud Protector Program require signing
separate Addendum with Terms & Conditions.
Docusign Envelope ID: 94EF8487-C4A4-8AD3-81A9-D6F4812DA66D
V 02-18-2026
Corpay’s General Terms & Conditions for Use of Fuelman Fleet Cards
Applicable to OMNIA Partners Participating Public Agencies using the Region 4 ESC
Master Agreement No. R260401 for Fuel Card Services
Summary of Rates, Fees, and Other Costs
1.1 Security, Loss, Theft, or Unauthorized Use of Card.
1.1.1 General Security. Each fuel card (“Card”) can be programmed to only allow Fuel or both Fuel &
Maintenance services such as oil changes, vehicle washes, etc. Typically, each transaction is authorized with the
Card number, product code, quantity and driver’s Driver ID across the proprietary Fuelman network to ensure that
the purchase is authorized and limited to the product and quantity (e.g. gallons of Fuel or dollars of Maintenance)
that have been pre-approved. This system also helps prevent unauthorized Driver IDs and stolen Cards from being
used to make purchases. The product and quantity controls are subject to each merchant location’s POS
Authorization Limitations described herein.
1.1.2 Corpay’s Liability. In the event an unauthorized transaction occurs, subject to the limitations and
Customer responsibilities explained in this Section 1.1 and in the event that Customer’s account (the “Account”)
has been issued fewer than ten (10) Cards, Corpay will assume full responsibility for those purchases which occur
so long as Customer has complied with all its respective obligations and/or responsibilities set forth under Sections
1.1.3 and 1.1.4 included herein. If the Account has been issued ten (10) or more Cards, Customer assumes all
liability and responsibility for unauthorized transactions and/or Account activity.
1.1.3 Customer’s Responsibility. It is the responsibility of Customer to ensure proper security controls are kept
in place to protect the Cards and Driver IDs and that only authorized employees or agents of Customer use them
to make purchases. It is also the Customer’s responsibility to lock any inactive, misplaced, or stolen Cards and
Driver IDs immediately. Corpay is not responsible for fraudulent transactions made on unlocked Cards with valid
Driver IDs. Customer should use the online account application to lock Cards and Driver IDs instantly. Alternatively,
the Customer can contact Corpay Customer Service during regular business hours via fax or email with the
requested change, in which case Corpay will make the requested changes within 24 hours and assume
responsibility for any unauthorized purchases at that point. All transactions in which a valid/unlocked Card number
was used in conjunction with a valid/active Driver ID will be considered to be authorized transactions in which
Customer is fully responsible for payment. It is also the Customer’s responsibility to review the standard fleet
management reports and optional electronic mail or email exception alerts to identify potential purchasing
discrepancies. Customer should instruct its Cardholders to keep any record of their Driver ID separate from the
vehicle’s Card.
1.1.4 Lost or Stolen Cards. Customer shall report all lost or stolen Cards to Corpay immediately via phone call
or email to Corpay’s Customer Service department identifying the Card number and such other details concerning
the loss or theft of the Cards as are known by Customer. Customer shall be liable for all transactions made by lost
or stolen Cards until Corpay receives Customer’s written notice of such lost or stolen Cards. Customer and
Guarantor(s) agree to and acknowledge full liability for any losses resulting from any failure to promptly report the
loss and/or theft of Card(s) in accordance with the terms hereof.
1.1.5 Terminated Drivers. It is the Customer’s responsibility to lock a terminated driver’s Driver ID as explained
herein.
Important Note: Please review all of these materials so that you, Customer, are fully informed about your
terms and conditions. Please select “AGREE” to certify your agreement to each specific Program Fee(s)
included in the table below that you, Customer, are agreeing to pay Corpay Technologies Operating
Company, LLC (“Corpay”) in connection with your execution of this Agreement.
AGREE Category Fee Amount When Charged
Expedited Next Day
Air Card Shipping
Fees
Up to $35 per Card.
Charged when Customer requests
additional cards and requires expedited
next day shipping. Fee is generally
assessed on a per package shipped
basis.
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1.1.6 Merchant Limitations. The personnel (if any) at a Merchant Location are not the agents or employees of
Corpay and Corpay shall not be responsible for the products or services rendered by any of the Merchants or any
other liability or damage which arises from the action or negligence of the personnel of any of the Merchants, their
agents or their employees.
1.1.7 POS Authorization Limitations. Authorization controls are provided as a convenience to the Customer
and are not guaranteed to prevent unauthorized purchases. Specifically, depending on the particular point-of-sale
(POS) equipment and Fuel dispenser controls being used by a particular Merchant Location, the product type and
spending limit may not be enforceable prior to completing the transaction. In these situations, the transaction will
still be considered to be authorized, but will be identified as an exception on the Customer’s standard fleet
management report and reported via email if desired by Customer.
1.1.8 Claims. All claims for defective Fuel or Maintenance must be made to the Merchant operating the Merchant
Location where such Fuel or Maintenance was purchased. Any claim for defective Fuel or Maintenance is waived
by Client unless made in writing to Merchant, with a copy to Corpay, within fifteen (15) days from the date of the
purchase of the alleged defective Fuel or Maintenance giving rise to the claim.
1.2 Account Administration and Card Issuance.
1.2.1 Credit Limit. Upon receipt of notice of award of SOLICITATION/contract and signed credit applications
from Customer, Corpay will establish an aggregate spending limit for all the Cards issued to Customer under the
Account(s) (the “Credit Limit”) based on Corpay’s evaluation of the Customer’s creditworthiness. The initial Credit
Limit may have already been established (applicable to existing older accounts already using Fuelman cards issued
by Corpay). Corpay reserves the right to increase or decrease this Credit Limit at any time with or without providing
notice to Customer. So long as sufficient creditworthiness exists, the intention shall be to have sufficient credit limit
to meet the anticipated purchasing projections or purchasing history/activity of the Customer under the billing
frequency and terms provided in the relevant RFP response. The total outstanding balance (the amount Customer
owes Corpay) appears as the “Amount Due” or “Total Amount Due” on Customer’s statement. This is not a revolving
credit account. The Amount Due/Total Amount Due shown on each Account statement is due and payable by the
due date (“Due Date”) shown on the statement. The Amount Due/Total Amount Due includes current transactions,
applicable service fees, amounts past due, late fees, charges for returned checks and other applicable charges.
Corpay can accept late or partial payments, as well as payments that reflect “paid in full” or other restrictive
endorsements, without losing any of Corpay’s rights under these terms and conditions.
1.2.2 Administration of Cards. Customer shall be solely responsible for the use, maintenance, administration,
and security of the Cards and Driver IDs within Customer’s business, including, but not limited to, distributing Cards
to, and collecting Cards from, its employees and agents. Notwithstanding any other provision in these terms and
conditions, Customer is responsible for any loss and/or misuse of Cards by its employees and/or agents. See
Section 1.1 for more information regarding Customer responsibilities.
1.2.3 Account Administration (Contact Persons). To ensure effective communication between your Fleet
Manager or Card Program Administrator, your Accounts Payable Representative, and Corpay, Customer will
provide the requested contact information for both an authorized Fleet Contact and Billing Contact. Up-to-date
information about your account will be communicated through these designated persons. For example, if your
account becomes past due or exceeds the assigned credit limit, or if we have identified suspected fraudulent activity,
the listed individuals on the account may be notified electronically to avoid a disruption in service or to confirm
whether suspected fraudulent purchases identified are legitimate. Customer shall contact Corpay’s Fuelman
customer service department or your account manager if any of this information changes for the authorized Fleet
Contact or Billing Contact person.
1.2.4 Cancellation of Cards. If, at any time, for any reason, Customer desires to cancel any particular Card,
but not the Account, Customer’s Representative must notify Corpay via the online application or in writing of such
cancellation. Customer’s liability for purchases made using the canceled Card shall when Corpay receives written
notice of such Card cancellation. The on-line application allows customer to instantly cancel (lock) cards.
1.2.5 Suspension of Cards. Corpay, at its sole discretion, may suspend or terminate the use of any Card at
any time for any reason, including, but not limited to, inactivity, unusual activity, or suspected loss, theft, fraud, or
in compliance with the USA Patriot Act. However, nothing in these terms and conditions shall obligate Corpay to
monitor the use of any Card, and, as described in these terms and conditions, Customer is solely responsible for
the use of any outstanding Cards.
1.2.6 Suspension of Account. Corpay, reserves the right to suspend or terminate the use of an Account due
to substantial change in creditworthiness, late payment (excessive days beyond terms), aggregate outstanding
balance owing on the Account (outstanding Account balance and unbilled transactions) over the Credit Limit or in
compliance with the USA Patriot Act.
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1.3 Limitation of Liability; Force Majeure; Modifications; Miscellaneous.
1.3.1 Limitation of Liability. THE PARTIES WILL HAVE NO LIABILITY FOR INDIRECT, SPECIAL,
CONSEQUENTIAL, PUNITIVE, OR INCIDENTAL DAMAGES OF ANY KIND, INCLUDING CLAIMS FOR LOSS
OF PROFITS, WHETHER RESULTING DIRECTLY OR INDIRECTLY TO CUSTOMER, CORPAY, GUARANTOR,
OR THIRD PARTIES, AND WHETHER ARISING IN CONTRACT, TORT, OR OTHERWISE, EVEN IF SUCH
DAMAGES WERE FORESEEABLE OR RESULT FROM A BREACH OF THESE TERMS AND CONDITIONS. IN
THE EVENT A COURT IN A FINAL, NON-APPEALABLE AWARD FINDS CORPAY OR CUSTOMER LIABLE FOR
ANY DIRECT DAMAGES, CORPAY OR CUSTOMER’S LIABILITY IN THE AGGREGATE FOR SUCH DIRECT
DAMAGES WILL NOT EXCEED THE AMOUNT PAID OR PAYABLE BY CUSTOMER TO CORPAY FOR THE
THREE (3) MONTHS PRECEDING THE DATE ON WHICH THE CLAIM AROSE.
1.3.2 Force Majeure. Corpay shall not be liable for failure to perform when such failure is occasioned or caused
by an act of God or other circumstances beyond its control.
1.3.3. Modifications. Unless otherwise set forth herein, any material amendments, modifications, and/or
changes to these specific “Corpay’s General Terms & Conditions for Use of Fleet Cards Applicable to OMNIA
Partners Participating Public Agencies using the Region 4 ESC” may only be effectuated through a written
agreement or instrument which has been duly executed by both Corpay and Customer.
1.3.4. Miscellaneous. These terms and conditions: (a) will be governed by the laws of the state where the
Customer is domiciled, without regard to its conflicts of laws principles, (b) may be assigned by either party only
upon the prior written approval of the other party which will not be unreasonably withheld conditioned or delayed;
(c) will be binding on the parties’ successors and permitted assigns; (d) together with the RFP response, as
applicable, constitute the entire agreement of the parties with respect to its subject matter; supersedes all prior
agreements and understandings, oral or written, of the parties with respect to this subject matter; and except as
expressly set forth in these terms and conditions, may only be modified by a writing signed by Corpay and Customer
or by Customer’s acceptance of additional or substitute terms delivered to Customer by Corpay via phone, website,
email, text, or such other means as may be elected by Corpay; and (e) do not create any partnership, agency
relationship, or joint venture. If any provision of these terms and conditions is found to be fully or partially invalid or
unenforceable, it will be enforced to the extent permitted by law, and the remainder will not be affected. No waiver
of any provision of these terms and conditions will constitute a waiver of the same provision on another occasion.
The rights and obligations of these terms and conditions which by their nature are intended to survive expiration or
termination will so survive. Customer and Corpay agree that any electronic signatures used in connection with
Corpay’s General Terms & Conditions are intended to authenticate this writing and to have the same force and
effect as a manual signature.
ACCEPTED AND AGREED:
Customer Name: City of Fayetteville
Signature:
Printed Name: Molly Rawn, Mayor
Date: 08/26/2026
Docusign Envelope ID: 94EF8487-C4A4-8AD3-81A9-D6F4812DA66D
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Electronic Funds Transfer Enrollment Request
To enroll your fuel card account in electronic funds transfer (EFT) or managed autopay payment service, please provide us, FleetCor
Technologies Operating Company LLC (“FleetCor”) with the following information and enclose your blank, voided check for the
account which FleetCor will withdraw your payments.
Account Information
_____________________________________________
Application # / Account #/ Account Code / BG #
_____________________________________________
Company Name
_____________________________________________
Billing Address
_____________________________________________
City / State / ZIP Code
_____________________________________________
Primary Contact Name
_____________________________________________
Primary Contact Email
_____________________________________________
Business Phone Number
_____________________________________________
Fleet Card Product
Enrollment Information
Information of Account to be Debited
Account Type: Commercial Checking Commercial Savings Other: ________________
Name of Institution: ____________________________________ ____ _
Name on Bank Account: __________________________________ __ ____ _
Address on Bank Account: __________________________________ __ ____ _
City, State, Zip Code on Bank Account: __________________________________ __ ____ _
ABA Routing Number: ____________________________________ __ __
Account Number: ____
Electronic Fund Transfer Acknowledgement
Please note that your depository account will be set up to be drafted automatically if your account has one of the following payment
terms:
If Weekly - Net 7 days or less
If Semi-Monthly or Bi-Weekly - Net 14 days or less
If Monthly - Net 25 days or less
The EFT / autopay service is not eligible for accounts that have payment terms other than those listed above. If at any time the
payment terms on your account change to terms that are not eligible for the EFT / autopay service, the EFT / autopay service will be
discontinued and you will need to establish other payment arrangements for your account.
You must maintain a current email address on file for electronic invoice delivery and have online user credentials. You are required to
add your banking info online to complete the setup process. If your due date falls on a weekend or holiday, the payment will be
posted the next business day (and your payment will not be deemed late).
If your bank account has any fraud controls, positive pay, or other restrictions, you must provide authorization to your bank for
Company Code: FLEETCOR – 2201912242 to allow the payment to draft your account. If you have these controls and do n ot notify
your bank, the payment will be returned and your account will be locked.
Terms and Conditions
My signature below indicates my acceptance of these terms and acknowledges that I am authorized to bind the payor Company
listed above to provide such approval. FleetCor will debit the above referenced account as I have instructed. If the Deposi tory
Institution returns an electronic debit request to FleetCor for any reason, (i) a Service Fee of $50.00 will be assessed, and (ii) my
Arvest Bank
City of Fayetteville
113 W Mountain St
Fayetteville, AR 72701
082900872
XXXXXXXX
City of Fayetteville
113 W Mountain St
Fayetteville, AR 72701
dsmallwood@fayetteville-ar.gov
479-575-8274
Deborah Smallwood
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cardholder privileges may be temporarily suspended (the account locked to further charges) until such time that the debit ent ry is
honored or other payment arrangements to bring the account to a current payment status are made.
I hereby authorize and request FleetCor Technologies Operating Company LLC (“FleetCor”) to electronically withdraw funds from
my account based on the payment terms established with FleetCor that are disclosed in the welcome letter, or account statements,
invoices, or other disclosures, as may be provided and/or updated by FleetCor from time to time.
I understand the amount to be debited will vary based on the total amount due on my most recent statement less any new
payments that may have been posted to the account after invoicing. I hereby waive my right to 10 days’ advance notice of the
exact amount to be withdrawn. In the event if on the first attempt to withdraw the funds, the payment is returned as insufficient
funds, I authorize FleetCor to initiate a second attempt to withdraw the funds within 3 days. In addition, if an adjustment for an
entry made in error is required I also provide FleetCor with my authorization to make the adjusting entry. I also represent that the
cited account has been set up in the name on the account stated above. This authorization will remain in effect until I revoke my
authorization, which I may do so at any time by sending email to EFTrequests@fleetcor.com (preferred), calling Customer Service
number on the back of the card, or in writing mailed to FleetCor PO BOX 923928 Norcross, Georgia, 30092, allowing up to 15 days
to terminate the arrangement.
_____________________________________________
Authorized Signature
_____________________________________________
Authorized Signor - Printed
___________________________________________
Date
New Banking Information: On a regular basis, FleetCor is instructed to withdraw funds based on the standard billing terms for Company’s
FleetCor Account until other written instructions are received by FleetCor.
Updated Banking Information: On a regular basis, FleetCor is instructed to withdraw funds based on the standard billing terms for
Company’s FleetCor Account until other written instructions are received by FleetCor.
Banking Verification
Please tape your voided check on the copy of this form you are returning to FleetCor. We cannot obtain acceptable banking
information from deposit slips. Place your check on the space provided so that the bottom left corners are aligned. This will help you
identify the necessary bank information to initiate electronic payments. Note: If a savings account is being used, you must check
with your bank to obtain the correct bank transit routing number and account number for electronic withdraw.
Return Instructions
Please scan and return both pages of this form to EFTrequests@fleetcor.com or fax to (678) 969-7762
Please allow 15 days for changes to take place.
Once EFT / autopay is turned on in our system, you will receive a confirmation email with instructions to add your banking info to complete the final
setup so the autodraft can begin.
For Office Use Only:
Molly Rawn - Mayor
08/26/2026
Docusign Envelope ID: 94EF8487-C4A4-8AD3-81A9-D6F4812DA66D