APPLICATION FORM
1. CUSTOMER DETAILS
Company Name:
Trading Address:
Postcode:
Business Entity Type: VAT Reg. No.:
Company Registration No.: Number of years trading:
Does the business operate internationally? YES NO
First Name: Surname:
Email Address:
Role in Company:
Landline No.: Mobile No.:
Estimated Monthly Usage:
Diesel: Unleaded:
Vehicle Type:
Car: Van: LGV: HGV: Coach: Motorbike: Other:
Total number of vehicles: How do you currently refuel?
If card please state
your supplier:
Please provide email address for online Velocity Portal:
2. STANDARD INVOICE / PAYMENT TERMS
Invoices are issued on a weekly basis and payment is by Direct Debit on or before the 7 Days Following Invoice Date.
I/We have read the Card terms and conditions of Use and agree to abide by them.
I/We confirm that the information given on this application and direct debit mandate is true and correct.
I/We agree and understand that WEX EUROPE SERVICES (UK) 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.
Authorised Signature of
Date:
Company:
Full Name of Signatory:
Position Held in Company:
WEX EUROPE SERVICES (UK) LIMITED
Registered in England and Wales. Registered Office: Hyphen Building, Floor 7, 75 Mosley Street, Manchester, M2 3HR Registered Company No: 08903805 VAT No: 176 2276 92
1. CUSTOMER DETAILS
Company Name:
Trading Address:
Postcode:
Business Entity Type: VAT Reg. No.:
Company Registration No.: Number of years trading:
Does the business operate internationally? YES NO
First Name: Surname:
Email Address:
Role in Company:
Landline No.: Mobile No.:
Estimated Monthly Usage:
Diesel: Unleaded:
Vehicle Type:
Car: Van: LGV: HGV: Coach: Motorbike: Other:
Total number of vehicles: How do you currently refuel?
If card please state
your supplier:
Please provide email address for online Velocity Portal:
2. STANDARD INVOICE / PAYMENT TERMS
Invoices are issued on a weekly basis and payment is by Direct Debit on or before the 7 Days Following Invoice Date.
I/We have read the Card terms and conditions of Use and agree to abide by them.
I/We confirm that the information given on this application and direct debit mandate is true and correct.
I/We agree and understand that WEX EUROPE SERVICES (UK) 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.
Authorised Signature of
Date:
Company:
Full Name of Signatory:
Position Held in Company:
WEX EUROPE SERVICES (UK) LIMITED
Registered in England and Wales. Registered Office: Hyphen Building, Floor 7, 75 Mosley Street, Manchester, M2 3HR Registered Company No: 08903805 VAT No: 176 2276 92
