Please complete sections 1 to 5. All fields marked * are required fields.
1. CUSTOMER DETAILS
Company *
Name		         Main Contact Name *
Address 1 *         Telephone *
Address 2         Mobile
City *         Fax
County         Email *
Postcode *         Rep Code

No. Years Trading *         No. of Vehicles *

Estimated Monthly Card Usage (litres)
Desired Invoice Format *   
Petrol         Diesel

  



How do you currently refuel on the road? *
If Fuel Card, please state current supplier:



If a Non limited Company please complete the following section:

Proprietors Name    
Home Address 1  
Home Address 2  
City  
County  
Postcode  

2. TRADE REFERENCE

Company *
Name		         Contact Name *
Address 1 *         Address 2
City         County
Telephone *         Postcode *
Email *            
               


3. CARD ORDER DETAILS

Customer Name (to appear on cards)   
Maximum 20 Letters including spaces *
Number of cards required *

Card 01
        
Card 02
Card 03
       
Card 04
Card 05
       
Card 06
Card 07
       
Card 08
Card 09
        
Card 10


4. DIRECT DEBIT MANDATE
INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY DIRECT DEBITS
Bank / Building Society Name *       Account No. *
   
Address *     Sort Code *  
   
    Name(s) of Account Holders *
   
Postcode *      

5. STANDARD INVOICE / PAYMENT TERMS

Invoices are issued on a weekly basis and payment is by Direct Debit on or before the 10th day following date of invoice. I/We have read the Card Terms and Conditions of Use and agree to abide by them and I/we confirm that the information given on this application and direct debit mandate is true and correct. I/We agree and understand that Carlton Fuels Limited shall not be obliged to accept this application nor to give any reason for refusing the same, nor to enter into any correspondence in regard there to. Credit checks will be made using information contained in this application.





 
 


 
 
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