Station Enrollment Form 2021.docx

Fixed Volume Discount Request

1. Complete sections A, B, and C as required.

2. Be sure to sign the form.

3. Fax completed form to: 207-253-1379. For questions, call Merchant Support at 800-492-0669 and follow the prompts for ” accepting merchant.”

A. MERCHANT INFORMATION

Type of Request (select one):

|_| Set up New Discount |_| Revise Existing Discount |_| Terminate Existing Discount (skip section B)

Merchant Name:

Merchant Contact:

Phone:

FAX:

Email:

Address:

City:

State:

Zip:

B. DISCOUNT INFORMATION

Merchant hereby agrees to reimburse WEX for the cent per gallon rebate for gasoline and/or ____cent per gallon rebate for diesel, and/or cent per gallon rebate for fuel other that WEX shall provide to the fleet listed below.purchased by such Fleet at the locations listed below. IT IS THE RESPONSIBILITY OF MERCHANT TO NOTIFY WEX OF ANY CHANGES TO THE SITE LIST SUCH AS A CHANGE NETWORK, BRAND AFFILIATION OR OWNERSHIP OF THE SITE. FAILURE TO DO SO WILL RESULT IN DISCOUNTS NOT BEING PROPERLY APPLIED TO THE FLEET ACCOUNTS.

Site List

(for additional sites, attach a separate list)

C. FLEET INFORMATION

The discount described above will be provided to the below fleet only:

Fleet Name:

Contact:

Title:

Mail Address:

City:

State:

Zip:

Will the discount offered apply to all participating entities that use the Fleet’s contract (such as other municipalities or government entities)? |_| YES or |_| NO

D. TERMS

1. The terms herein amend your agreement with WEX BANK for the acceptance of WEX issued or serviced Cards (WEX Cards) as it relates to providing discounts to designated fleets. All other terms and conditions remain in full force and effect.

2. The merchant is responsible for the accuracy of information supplied, and WEX shall not be responsible for any errors or omissions in such information. WEX shall not be responsible for any errors in processing the requested volume discounts. Discounts cannot be retroactive from the date of entry into the WEX system.

3. If Merchant is paid directly by WEX for card sales at the sites listed on Page 1, then WEX shall apply the agreed upon discount amount to each transaction for the applicable fleets as part of its transaction processing. Merchant will be paid by WEX for the card sale less the discount set forth herein as part of their settlement that they receive directly from WEX.

4. If Merchant is offering this discount through a location that it owns or operates, but for which it accepts WEX cards through agreements with their fuel supplier, WEX shall calculate the net total gallons sold using WEX Cards on a quarterly basis. A repoirt shall be generated showing the net total gallons sold by the 20th of the month for the preceeding quarter. WEX shall also send an invoice fo rthe amount of the Rebate Fee due in accordance with Section B above. The invoice shall be due net 30 days. In the event the invoice is not paid within such time, a late fee of 1 ¾% per month or 21% per annum shall apply.

4. Either party may terminate the discounts listed on this Discount Request form at any time upon delivery of written notice of termination at least thirty (30) days prior to the effective date of such notice. The parties shall continue to be liable for their duties and obligations incurred prior to the effective date of notice.

5. The parties agree that a signed facsimile transmission shall be considered valid for purposes of this Discount Request form and that the parties hereby waive any claim that a facsimile transmission does not satisfy the requirements of a signature or writing under applicable law.

E. SIGNATURE

By signing this Fixed Volume Discount Request form, you are indicating that you have the authority to bind the Merchant to this Request and the terms contained herein.

Authorized Merchant Signature:

X Date:

Print Name:

Title:

Fleet Account Number (If available):

The information contained in this facsimile message is intended only for the use of the individual or entity named above and contains confidential information. If the addressee of the message is not the intended recipient, or the employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by calling 1-800-492-0669 and return the original message to the attention of the sender, at the address listed above.

WEX.FUELSUP.FXD.DISC.CTS WOUT FEE (03/13)

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