Brokenstraw Airport LLC

Pittsfield, PA    -   814-563-3166

R. William Holder   -   Owner

P.O. Box 134 - Pittsfield, PA 16340

FUEL CARD REQUEST

Name __________________________________________________________

Address ________________________________________________________

               ________________________________________________________

City / State _________________________________   Zip Code ___________

Telephone _____________________                        E-mail ________________

Bank Name & Address ____________________________________________

                                        ____________________________________________

                                        Bank Telephone ___________________

       I authorize Brokenstraw Airport to issue a Fuel Charge Card in the name shown above and  I also acknowledge that I am responsible for the payment for all charges made on that card.

                                                                     Signature  _________________________

                                                                             Date  _________________________

Please Return To:  Brokenstraw Airport LLC

P.O. Box 134

Pittsfield, PA 16340