fuelcard.certaireland.ie

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*

Address Line 1*

Address Line 2

Street Address

City*

City

Postal Code*

ZIP / Postal Code

County*

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

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Date of Birth*

DD slash MM slash YYYY

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Phone Number*

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Email Address*

Previous Fuel Card Use*

Yes

Previous supplier*

Signatures & Terms

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Signature of Applicant*

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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 (€)

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Authrorised Products*

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*

I consent to data processing in compliance with Certa’s Data Transparency Notice

Terms and Conditions Acceptance*

I consent to the Fuel Card terms and conditions

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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.

Fuel Card Account Set Up