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*Required Fields

*Account Last Name:
*Account First Name:
*Farmers Cooperative Account Number:
Farmers Cooperative Fuel Card Number (please enter if known):
*What type of fuel card is needed?:	New card Duplicate card (same pin # and card # as current card)
*Do you wish to deactivate a current card?:	Yes No
Phone Number:
Email Address:
Street Address:
City:
State:
ZIP Code:
Pin Number:
Notes:
Security code: