Fuel Card Form

Section One - Applicant Details

Applicant Name *
Legal Status *
Vat Number *
Nature of Business
Company Web Site
Years & Months Trading *
/
Trading Address
Address 1 *
Address 2
Town *
County *
Country *
Postcode *
Time at Current Trading Address *
/
Previous Trading Address
Address 1 *
Address 2
Town *
County *
Country *
Postcode *
Do you have a Different Invoice / Head Office Address?
Yes
Invoice / Headoffice Address
Address 1 *
Address 2
Town *
County *
Country *
Postcode *

Section Two - Requirements

Est. Monthly Volume *
Current Supplier *
Fleet Size Cars
Fleet Size Van
Fleet Size Lorry
Fleet Size HGV
Additional Requirements
How Did you hear about Maxol Fuel Cards *
Other Please Specify

Section Three - Contacts

Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *
Add another contact?
Yes
Title
Contact First Name *
Contact Surname *
Role in Organisation *
Contact Email *
Contact Phone *
Contact Mobile *

Section Four - Proprietor/Directors/Partners Details

Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *
Add another Director?
Yes
Title
Director First Name *
Director Surname *
DOB (dd-mm-yyyy) *
Home Address 1 *
Home Address 2
Town *
County *
Country *
Postcode *

Section Five - Authorisation

Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
Add another Signatory?
Yes
Authorised Signatory *
Authorise Date *
Organisation Role
Email Address *
I / We Agree to the Maxol Fuel Card Terms and Conditions of Use:
Yes
I / We would like to be kept informed of the latest news and offers from the Maxol Group:
Yes
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