TripCheck – Fuel Form

Part 1: Business Name and Public Street Address (information released to the public)	

**All items in bold must be filled in***

Business Name: _______________________________________________________________
Street Address: ________________________________________________    Suite: ________
City: ______________________     State: Oregon     Zip: ____________
Chain Affiliation:    □ Arco   □ BP   □ Chevron   □ Mobile   □ Shell   □ Texaco   
□ Other, Specify: _______________________________   □ Do not display for this listing

Part 2: Business Profile (information released to the public)	

**All items in bold must be filled in***

Facility Description	

ADA Accessible:    □ Yes   □ No
Hours of Operation: (1 paragraph, 250 characters max.) ____________________________________________
_____________________________________________________________________________________

Fees: (1 paragraph, 250 characters max.) _________________________________________________________
_____________________________________________________________________________________

Facility Description: (1 paragraph, 400 characters max.) ____________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
Fuel Type:    □ Regular    □ Super    □ Diesel    □ Propane
Amenities:    (can only show items from this list)   □ Car Wash    □ Lodging    □ Market    □ Mechanic    
□ PUC Discount    □ RV Facilities      □ RV Friendly    □ Tire Service    □ Towing    □ Trucker Facilities
Payment Options:    □ Cash   □ VISA   □ MasterCard   □ Discover   □ American Express   □ Check

Public Contact Info	

Phone: __________________     Toll-Free: __________________     Fax: __________________     Email: ___________________     Website: ____________________________________________

Directions from Nearest Route (highway)	

Route: _______   Milepost: ______   Longitude: __________________   Latitude: _________________

Map URL: ____________________________________________________________________________

Directions from Route: (1 paragraph) ________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
We can also include a small picture, or logo, for your business. (We are limited to a picture width of no more than 150 pixels but will be happy to resize your picture for you.)

Part 3: OTE Business Contact (not released to the public)	

**All items in bold must be filled in***

Primary Contact Info	

First Name: _________________________     Last Name: _________________________   
Phone: _____________________________     Fax: _______________________________                 
Email: ______________________________

Alternate Contact Info (optional)	

First Name: _________________________     Last Name: _________________________   
Phone: _____________________________     Fax: _______________________________                 
Email: ______________________________

Owning Business and Mailing Address	

□ Same as the public business name and street address?

Owning Business Name: _________________________________________________________________
Address 1: __________________________________   Address 2: _______________________________
City: ______________________     State: _______________     Zip: ___________

Payment method:
 □ Check Enclosed
 □ Invoice Me

Subscription rate: $ 150.00 per year. 
Mail your completed form to:
Oregon Travel Experience
ATTN: Tripcheck Link Subscription
1500 Liberty St. SE, Suite 150
Salem OR 97302

or
				
Email: info@oregonte.com 		Questions? Call 1-800-574-9397 and choose Sue VanHandel or zero for Operator

or

Fax:  503-378-6282