Call: 402-223-3221

*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

Card Pickup Location

Phone Number:

Email Address:

Street Address:

City:

State:

ZIP Code:

Pin Number:

Notes:

Security code: