Existing customers may use this form to request a new card. For help, please call 1-800-444-5823 and ask for Firebird Customer Service.

Account Number: Company: Requestor Name: Address: City: State: Choose a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Phone:

Fuel Type: Tax Class (if diesel): Gallon Limit: Diesel Diesel + Unleaded Diesel + All Gas All Gas(Unl, Mid, Prm) Unleaded Mid Grade Premium Unleaded + Midgrade Red-Dyed Diesel GNG + LNG Heavy Light non-Industrial 10 20 30 40 50 75 150 250 500 999 Vehicle #: Optional Card Label: # of cards Requested:

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