1. Company Information

*Corporate Name Corporate Parent Name *Corporate Tax ID Number

*Corporate Address *City

*State *Zip Code

*Type Of Business Corporate Website Address

2. Company Officer

*Corporate/Business Title *First Name *Last Name

*Business Phone Number *Business Email Address (No Personal Email Address) *Confirm Email Address (No Personal Email Address)

*Business Fax Number

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3. Secondary Company Officer.

*Corporate/Business Title *First Name *Last Name *Business Fax Number

*Business Phone Number *Business Email Address (No Personal Email Address) *Confirm Email Address (No Personal Email Address)

3. Other Manufacturer's Corporate Account Number.
Yes
No

Manufacturer Account Number Fleet Management Company

4. Dealer Information.
Yes
No

Dealer Name Dealer Contact First Name Dealer Contact Last Name

Dealer Code Dealer Phone Number

Business Email Address Confirm Email Address

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5. Instructions for Corporate Account Registration.

To qualify as a registered corporate account, a company must meet the following criteria:

1) Operation of 15 or more vehicles (any make or model) registered in the company name.

2) Hard copy vehicle registrations must be provided after completing this form. Registrations in individual names, titles, or insurance cards are not accepted. Registrations must be for motor vehicles only; no trailers, boats, motorcycles, machinery, etc.

3) For leased vehicles, in addition to the registrations in the leasing company's name, a Buyer's Order or Lease Agreement or Master Insurance Policy listing the VINs to the company applying for the CAN.

Please use this portion of the form to attach proof of registration for 15 company-owned/leased vehicles. If you are unable to attach scanned copies of your documents, you must fax the documents to Fleet Operations at 201-263-7313. Review of applications will begin when all supporting documents have been received.

Note: Review of applications will begin when all supporting documents have been received. Please allow up to two business days for processing.

Upload Registrations/Lease Documents
I prefer to fax my 15 vehicle registrations and/or lease documentation to 201-263-7313.

Review of your application can only begin after all supporting materials have been received.

*Vehicle	*Last 8 Characters of the VIN	*Manufacturer	*Model	*Year	*Registration Expiration Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

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6. Upload Registrations/Lease Documents

1. Click "Browse" to select a file. 2. Only .PDF and .DOC files are accepted. 3. For leased vehicles, Buyer's Order, Lease Agreement, or insurance company list must be included. 4. All supporting paperwork must be included in one file for upload.

Select Registrations/Lease documents file

7. Account Application Agreement.

By submission of this Qualified Corporate Account Enrollment Form, the undersigned hereby requests enrollment as a Registered Corporate Account and agrees to comply with the Official Program Rules with respect to any Mercedes-Benz incentive benefits as outlined in Official Program Rules. We acknowledge that this enrollment form will be continued from year to year and, as a condition of continued enrollment as a Fleet Program Qualified Corporate Account, we agree to comply with the Official Rules of the Programs, including applicable limitations and restrictions, established from time to time.

1. Mercedes-Benz USA, LLC reserves the right at its sole discretion to change program rules and guidelines and fleet incentives without notice, to verify accuracy of account data, to decline an application or to terminate a Corporate Account Number or Executive Allowance Control Number at any time on a case by case basis. All program transactions are subject to audit and chargeback to the dealer. 2. Purchaser hereby agrees that any information provided to or obtained by Dealer or MBUSA in confirmation of the Purchaser's participation in the MBUSA Fleet Program (including any and all personal information), is voluntarily provided by Purchaser and Purchaser hereby consents to MBUSA and Dealer's retaining said information for record and audit purposes and to the sharing of said information to affiliates and agencies for purposes of marketing Mercedes-Benz products and services. 3. Dealer and customer acknowledge and agree that MBUSA's issuance of a CAN or control number or approval under the MBUSA Fleet Program does not constitute an approval of or review by MBUSA of any transaction effected through the Program. It remains the Dealer's and Purchaser's responsibility to determine and comply with all Program qualifications of any transaction including compliance with use, export and resale restrictions. 4. Sale subject to any new car sales DDR Policy and Export Policy. Vehicles are intended for use in the USA and are subject to the limitations of the Export Policy. Fleet programs are not eligible for use with Brokers. Fleet incentive must be used at the time of purchase/lease.

8. Electronic Signature.

Title of Company Officer

Name of Company Officer

Date

1. I confirm that the information is complete, and accurate to the best of my knowledge and by submitting the application I have reviewed the Account Application Agreement and consent to the information being used for enrollment in the Mercedes-Benz Fleet Program.

Note: Review of your application will begin only after all supporting documents have been received. Please allow up to two business days for processing.

*(Electronic Signature of Company Officer) Yes,I agree.

2. By checking this second box, I also agree and consent for a copy of the approval/rejection email response to be sent to the above mentioned Mercedes-Benz certified dealership regarding this Corporate Account Number (CAN) Enrollment Application.

Please sign the form by selecting the Highlighted Checkbox. For accuracy, please review all the inserted data by simply clicking on the orange Prev icons for each page of the application, and then proceed to submit if everything is fine.

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Please select the reason for Rejection

*Type of Reason *Reason for Rejection (250 chars max).

Mercedes-Benz Fleet Program Corporate Account Enrollment