Fuel Card Request Form

*Account Last Name:

*Account First Name:

*CVA Account Number:

If you don't have a CVA Account, please first complete a CVA credit application located at: https://www.cvacoop.com/Home/Credit-Information

CVA Fuel Card Number:

Please enter, if known.

What type of Fuel Card is needed? :

Reissue Card
New Issue Card (Additional Card on Existing Account)

Do you wish to deactivate a Current Card?:

Yes
No

*Phone Number:

Email:

*Please send fuel transaction receipts to my email address?:

Yes
No

*Street Address:

Address Line 2:

*City:

*State:

*ZIP code:

*Number of Cards Requested:

*Create 4-digit PIN Number: