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ADDENDUM TO THE FUEL CARD SERVICES AGREEMENT BETWEEN WRIGHT EXPRESS FINANCIAL SERVICES CORPORATION ("WEX FSC ") AND THE STATE OF FLORIDA DEPARTMENT OF MANAGEMENT SERVICES (the " STATE ") CREDIT INFORMATION Participating Entity agrees that in the event the account is not paid as agreed , WEX FSC may report the undersigned' s liability for and the status of the account to credit bureaus and others who may lawfully receive such information . Participating Entity Phone # Fax# Business Name and Physical Address (Do not include PO Box) Applicant' s Taxpayer ID # (TIN , FEIN or SSN ) In Business Since (yyyy) Year of Incorporation (yyyy) Number of Vehicles Avg Monthly Fuel Expenditures Avg Monthly Service Expenditures $ $ ACCOUNT SETUP INFORMATION Write Participating Entity name as you wish it to appear on cards . Limit of 20 characters & spaces . Unless specified, no company name will appear on cards . Billing Contact Billing Address City State Zip+4 Designate the Fleet Contact authorized to receive all charge cards, reports , and other such information we provide from time to time and to take actions with respect to your account and account access. This is also the person designated by your company to provide all fleet vehicles , driver and other information we may request. Authorized Fleet Contact Name Title Phone # Fax # Mailing Address (if different from billing address) City State Zip+ 4 Email address ( required to take advantage of product type card controls) Card Controls : To help us estimate your credit needs, indicate the types of cards you anticipate using . If you provide a valid email address above, you can select from these product type options : ❑ All Products ❑ Fuel & Service ❑ Fuel & Fluids with Roadside Assistance ❑ Fuel with Roadside Assistance ❑ Mix of card types ❑ Check here if business is exempt from motor fuels tax DEFINITIONS : "Agreement" means : Contract No.973A 63-10-1 effective August 6 , 2010 for Fuel Cards and Fuel Management Services (the "Agreement") between the State of Florida Department of Management Services and WEX FSC . " Participating Entity" shall mean the Participating Entity as defined in the Agreement permitted to purchase services under the Agreement, as specified in the Credit Information above . All other capitalized terms used in this Addendum without definition have the meanings set forth in the Agreement. AGREEMENTS OF WEX FSC AND PARTICIPATING ENTITY: 1 . This Addendum is to allow the Participating Entity to participate under the Agreement between WEX FSC and the State . It does not modify , amend or change the Agreement in any way . 2 . Participating Entity represents that it is authorized or allowed by the laws of its home state to enter into this Addendum and to participate under the. : . . . Agreement. 3 . Participating Entity hereby requests the services of WEX FSC described in the Agreement and agrees to perform all duties of a Partin ti ity under�i� the Agreement, including , without limitation , payment of all charges on its account(s ) within the time periods provided under the Agr"9pera t , nt fees provided in the Agreement, and cooperation with respect to providing all necessary information for the administration of the AgM�O ent. Entity agrees to be bound by the terms and conditions of the Agreement , including , without limitation , rules for authorized and unau�t6ri2ed use disputes of charges , reporting lost and stolen cards , and all other rules and provisions relating to use of Participating Entity's accourj. of ' If failure to make timely payment in accordance with the terms of the Agreement 4 . Participating Entity acknowledges that its and/or the A% um m suspension or cancellation of the account(s ) . The undersigned represents and warrants that he/she is duly authorized to execute this i �`rWf ; ' of the Participating Entity and this Addendum is the valid and binding obligation of the Participating Entity, enforceable in accordance eir p rpU ;.° INFORMATION SHARING DISCLOSURE : Information regarding your transactions may be provided to the State , accepting merchants or their serv`fireifiYTdef�"»» to facilitate discounts or other promotional campaigns of interest to you . U . S .A . PATRIOT ACT : Our bank complies with Section 326 of the USA PATRIOT Act which requires all financial institutions to obtain , verify , and record information that identifies each company or person who opens an account. What this means for you : when you open an account, we will ask for your na e , address , date of birth , and other information that will allow us to identify you . We may also ask to see your driver's license or other identifying documents ur of business . DISCLAIMER: THIS IS AN APPLICATION FOR SERVICES AND SHALL NOT BE BINDING UPON WEX FSC UNTIL FINAL CREDIT APPRO HAS BEEN GRANTED BY WEX FSC . CONTRACTING AGENCY AUTHORIZED SIGNATURE REQUIRED km Any person signing on behalf of the Participating Entity has been duly y t�eFessary action of Applicant's governing body, and that the undersigned is authorized to make this a cation on behalf of the Participating Entik'[ � � Signature : G ted Name : Gar C Wheeler r Title : ' Date : i 7 2012 Complete a 'sign dum . Fax to 866 -527 -8873 . 2 oo . - . Oppty Number Sales Cod y' PlasType Coupon Code Account Number .. n 10914030``69 ^ .• • � 'F'L2 FL2 04 �T 04 . ADDEND . CRDAPP ( 11 /08 ) ;111 11 ik A