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0818-550-550
Fuel Card Account Set Up
"
*
" indicates required fields
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2
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5
1. Basic Information
Name
*
First
Last
Email Address
*
Phone
*
Business Details
Business Name
*
First
I have authority to make this fuel card application on behalf of the company I have specified
*
I have authority to make this fuel card application on behalf of the company I have specified
*
Address Line 1
*
Address Line 2
Address Line 2
Street Address
City
*
City
Postal Code
*
ZIP / Postal Code
County
*
Select Your County
Antrim
Armagh
Carlow
Cavan
Clare
Cork
Derry
Donegal
Down
Dublin
Fermanagh
Galway
Kerry
Kildare
Kilkenny
Laois
Leitrim
Limerick
Longford
Louth
Mayo
Meath
Monaghan
Roscommon
Roscommon
Sligo
Tipperary
Tyrone
Waterford
Westmeath
Wexford
Wicklow
Company Reg No./VAT Number
Years of Trading
*
Please enter a number greater than or equal to
0
.
Business Type
*
Number of Fuel Cards Required
*
Please enter a number greater than or equal to
0
.
Estimated Monthly Fuel Usage (€)
*
Please enter a number greater than or equal to
0
.
Contact Information
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Contact Name
*
First
This field is hidden when viewing the form
Date of Birth
*
DD slash MM slash YYYY
This field is hidden when viewing the form
Phone Number
*
This field is hidden when viewing the form
Email Address
*
Previous Fuel Card Use
*
Yes
No
Previous supplier
*
Signatures & Terms
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Signature of Applicant
*
This field is hidden when viewing the form
Date
*
DD slash MM slash YYYY
Consent
*
I confirm I have read & understand the
fuel card terms & conditions
*
Fuel Card Details
Fuel Card Details
*
Driver Name
Reg Number
Weekly Limit (€)
Add
Remove
This field is hidden when viewing the form
Authrorised Products
*
Diesel
Petrol
HVO
Lubricants
Car Wash
Ad Blue
Marked Gas Oil
Please select all products that apply
Authrorised Products
*
Diesel
Petrol
HVO
Lubricants
Car Wash
Ad Blue
Marked Gas Oil
Please Unselect all products that don't apply
Submit your ID & Proof of Address
Payment switcher - DD/CC
*
Direct Debit
Credit Card
Payment Setup
Direct Debit Information
Bank Name
*
Account Holder Name
*
IBAN
*
BIC/SWIFT
*
A test transaction of €1 will be authorised and the equivalent credit will be left on your account once it is set up.
Direct Debit Information - Consent
*
I authorise direct debit setup
*
Credit Card Application
Tick This box
*
Tick this box if you wish to set up payments by credit card & our team will contact you to securely set up payments.
*
Security and Compliance
Data Consent
*
Data Consent
*
I consent to data processing in compliance with Certa’s
Data Transparency Notice
Terms and Conditions Acceptance
*
Terms and Conditions Acceptance
*
I consent to the Fuel Card
terms and conditions
This field is hidden when viewing the form
Credit Card Terms Acceptance
*
Credit Card Terms Acceptance
*
Specific agreement to the terms and conditions related to the credit card application.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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