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Fuel Card Application
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Fuel Card Application
Fuel Card Application
1
Introduction
2
Applicant details
3
Contact details
4
Other details
5
Sole Trader / Partners / Directors Names & Addresses
6
Trade references
7
Credit requirements
8
Fuel cards
Introduction
This application is for customers of Reliable Petroleum Pty Ltd ABN 54 602 197 375 who wish to establish a Credit Account for Bulk Fuel with Reliable Petroleum or who wish to be issued an OTR FuelCard (Application). Please contact us on (08) 8367 2000 for the full Terms and Conditions relating to the supply of Products by Reliable Petroleum, the use of a Credit Account or Bulk Facility and the terms of use of FuelCards issued by Reliable Petroleum (Standard Terms). The Standard Terms are also available on our website (www.otr.com.au or www.reliablepetroleum.com.au) and will be provided to you before your Credit Account or Bulk Facility can be used.
Please note that in this Application “Terms and Conditions” means this Application, the Standard Terms and the Direct Debit Request, Direct Debit Service Agreement, Privacy Agreement and Guarantee and Indemnity contained here in.
If the Applicant is a Company or an Incorporated Association, all Directors (or in the case of a sole director, all shareholders) must also complete and sign the Deed Poll of Guarantee and Indemnity.
This online form will generate a prefilled PDF for printing, signing and returning. We will also email it to the below address.
Email address
(Required)
Applicant details
I / We hereby apply for :
(Required)
Bulk Account
Fuel Card
with Reliable Petroleum in accordance with the Terms and Conditions and submit the following confidential information for this purpose only:
Bulk Delivery Location 1
Bulk Delivery Location 2
Bulk Delivery Location 3
Location and contacts:
(Required)
Pt Augusta
Pt Lincoln
Wudinna
Riverland
South East SA
Adelaide
Other
Select All
Sales Contact Name (if selected)
Entity Name (Trust, Ltd, P/L, Partnership or Sole Trader)
(Required)
Trust Name
Trading Name, if registered
Affiliated or Parent Companies
ACN (for Companies)
ABN
(Required)
Address
(Required)
Address
State
Postcode
Address 2
Postal Address (if different from above)
State
Postcode
Contact details
Contact Name for Account Enquiries
(Required)
Email
(Required)
Mobile
(Required)
Business Phone
(Required)
After Hours
(Required)
Contact Name for Operations
(Required)
Email
(Required)
Mobile
(Required)
Business Phone
(Required)
After Hours
(Required)
Other details
Description of Main Business
(Required)
Previous Fuel Supplier (if applicable)
Year Business Commenced
(Required)
Estimated Monthly Purchase
(Required)
Sole Trader / Partners / Directors Names & Addresses
Note: If more than five partners/directors please provide details on a separate page.
i) Full Name
(Required)
Telephone
(Required)
Address
(Required)
Address
State
Postcode
Date of Birth
(Required)
DD slash MM slash YYYY
Driver’s Licence Number
(Required)
ii) Full Name
Telephone
Address
Address
State
Postcode
Date of Birth
DD slash MM slash YYYY
Driver’s Licence Number
iii) Full Name
Telephone
Address
Address
State
Postcode
Date of Birth
DD slash MM slash YYYY
Driver’s Licence Number
iv) Full Name
Telephone
Address
Address
State
Postcode
Date of Birth
DD slash MM slash YYYY
Driver’s Licence Number
v) Full Name
Telephone
Address
Address
State
Postcode
Date of Birth
DD slash MM slash YYYY
Driver’s Licence Number
Has either the business or any of its directors ever had, or there are now, any legal judgements or proceedings filed against them?
(Required)
No
Yes (If yes, please provide details and attach to the application)
Trade references
Not finance / credit card or financial institutions
i) Company Name
(Required)
Contact
(Required)
Phone
(Required)
Email
(Required)
ii) Company Name
(Required)
Contact
(Required)
Phone
(Required)
Email
(Required)
iii) Company Name
(Required)
Contact
(Required)
Phone
(Required)
Email
(Required)
Credit requirements
Estimated monthly requirements (Minimum purchase must be over $1,000 per month)
PULP (litres)
ULP (litres)
Diesel (litres)
LPG (litres)
Lubes (litres)
Credit Limit for FuelCard $
(Required)
Credit Limit for bulk fuel $
(Required)
Please note that Reliable Petroleum may choose to open a Credit Account of Bulk Facility, or issue a FuelCard to an Account holder with a Credit Limit lower than that requested by the Applicant, at Reliable Petroleum’s sole discretion.
FuelCard fees & payment terms
A standard card fee of $1.10 per week shall be payable by the Applicant in respect of each FuelCard issued by Reliable Petroleum. The Applicant must also purchase more than $1,000 of products and services from merchants each month using the FuelCard or a further fee may be charged by Reliable Petroleum.
Reliable Petroleum will issue to the Applicant an invoice every Wednesday and the applicant nominated bank account will be debited every Thursday night.
Payment will be deducted from the Applicant’s nominated account in accordance with the Direct Debit Request and the Direct Debit Service Agreement. If payment is not made, default interest may be charged in accordance with the Terms and Conditions. Please list below vehicle details or other details to be assigned to each FuelCard. Despite nominating authorised vehicles or cardholders, the Applicant remains wholly responsible for the transactions relating to all issued FuelCards in accordance with the Terms and Conditions.
Card order form
Description (Name and or Vehicle Description)
Actions
Edit
Delete
There are no
Cards.
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Maximum number of cards reached.
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Description (Name and or Vehicle Description)
(Required)
Vehicle Registration Number (if applicable)
Requested PIN (4 digits only)
(Required)
Driver ID/Vehicle ID (optional)
Odometer Reading
Odometer Reading Required
Cost Centre (optional)
Products
(Required)
Regular Unleaded (91)
Premium Unleaded (95)
Ultimate Unleaded (98)
Diesel
AdBlue
LPG
Shop
Carwash
Lubes
Δ