New Assistance Group GOfuel Application Form

Perks GOfuel Application Form

*GOfuel 2025
Before you fill out your application, if you have any questions please see our FAQ
or call us on 0800 42 83 83. Please note that all GOfuel Accounts are settled by Direct Debit.
I am willing to fill out a direct debit form*

Yes
How did you hear about us?*
Account Type:*

Personal (must be 23 years or over)Business (must be incorporated 2 years or over)*
* For more information regarding your business, please call us on 0800 42 8383 ext. 903

Personal Account Details

*If this application is for a BUSINESS account please go back and select the 'Business' option.
Account Name:*
Customer's Full Name*

PrefixFirst NameLast Name
Phone Number*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Email:*
example@example.com
Occupation*
Employer*
Mailing Address*

Street Address

Street Address Line 2

CityCountry

Postal Code
Is your Physical Address the same as the Mailing Address?

YesNo
Physical Address*

Street Address

Street Address Line 2

CityCountry

Postal Code
Alternative Contact Person:

*This person may be contacted.
Contact Name:*

First NameLast Name
Contact Phone Number:*

Area CodePhone Number
Proof of Identification: Attach a copy of BOTH SIDES of your Driver's Licence.
Driver's Licence Number:*
Version OR 5b Number:*
Please attached a copy of Drivers Licence*

Browse Files

Cancelof
Signature*

Clear
* Use the left button on your mouse or touchpad and draw your signature in the signature box

Business Account Details

* If this application is for a PERSONAL account please go back and select the 'Personal' option.
Account Name:*
Business OR Legal Name:*
Director/Owner's Full Name:*

PrefixFirst NameLast Name
Phone Number:*

Area CodePhone Number
Mobile Number:

Area CodePhone Number
Email:*
example@example.com
Office Contact Full Name:*

PrefixFirst NameLast Name
Position:*
Work Phone Number:*

Area CodePhone Number
Mobile Number:

Area CodePhone Number
Email:*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityCountry

Postal Code
Is your Physical Address the same as the Mailing Address?

YesNo
Physical Address*

Street Address

Street Address Line 2

CityCountry

Postal Code
Proof of Ownership: Attach a copy of BOTH SIDES of your Director/Owner's Driver's Licence AND a copy of the companies Certificate of Incorporation.
Director/Owner's Driver's Licence Name:*
Licence Number:*
Version OR 5b Number:*
DOB:*

DayMonthYear
Please attached a copy of Drivers Licence and companies Certificate of Incorporation*

Browse Files

Cancelof
Signature*

Clear
* Use the left button on your mouse or touchpad and draw your signature in the signature box
We require two trade references. Please indicate who we can contact: *
Company Name
Contact Name *

First NameLast Name
Contact Phone Number *

Area CodePhone Number
Contact Email *
example@example.com
Company 2 *
Contact Name *

First NameLast Name
Contact Phone Number *

Area CodePhone Number
Contact Email *
example@example.com

Direct Debit Form
NAME OF ACCOUNT (AS PER APPLICATION FORM):*
CONTACT PHONE NO:

Area CodePhone Number
DIRECT DEBIT AUTHORITY
ACCOUNT HOLDER NAME:ACCOUNT HOLDER NAME:*
BANK ACCOUNT FROM WHICH PAYMENTS TO BE MADE:*
* Please do not add dashes or spaces e.g. 0201234267891000. ** Please ensure to provide a cheque account number as a savings account number will not work.
To: The Bank Manager,
Bank
Branch
Town/City
Proof of Ownership: Attach a copy of a Bank Statement showing the account owners name and address OR a copy of a Deposit Slip AND proof of Addresses (a recent copy of an account showing your current address i.e. utility account).
Please attached a copy of the Bank details document*

Browse Files

Cancelof
INFORMATION TO APPEAR ON MY/OUR BANK STATEMENT:
PAYER PARTICULARS
PAYER CODE
PAYER REFERENCE

How many Fuel Cards would you like?*
* Note for customers ordering more than 4 cards: Since you require 5 or more cards, you will instead be emailed a spreadsheet upon completion of this form, which you must complete and return.

** Cards ordered for Marine use: Mobil cards work at our marinas.

*** If you don't wish to order fuel cards, leave this field blank.
Would you like your cards couriered to you? ($10 Domestic, $20 Rural Delivery). Cards are sent via New Zealand Post.

YesNo

Fuel Card Details
Card 1 Details:
Details to be embossed on card: *
(Example: Driver Name, Boat Name, Vehicle Rego)
Fuel Card Required:*

Mobil
4 Digit Pin:*
IMPORTANT: Remember PIN number as this will not be sent to you.
Daily Credit Limit*
Minimum = $200.00
Monthly Credit Limit*
Purchase Codes*
Card 2 Details:
Details to be embossed on card: *
(Example: Driver Name, Boat Name, Vehicle Rego)
Fuel Card Required:*

Mobil
4 Digit Pin:*
IMPORTANT: Remember PIN number as this will not be sent to you.
Daily Credit Limit*
Minimum = $200.00
Monthly Credit Limit*
Purchase Codes*
Card 3 Details:
Details to be embossed on card: *
(Example: Driver Name, Boat Name, Vehicle Rego)
Fuel Card Required:*

Mobil
4 Digit Pin:*
IMPORTANT: Remember PIN number as this will not be sent to you.
Daily Credit Limit*
Minimum = $200.00
Monthly Credit Limit*
Purchase Codes*
Card 4 Details:
Details to be embossed on card: *
(Example: Driver Name, Boat Name, Vehicle Rego)
Fuel Card Required:*

Mobil
4 Digit Pin:*
IMPORTANT: Remember PIN number as this will not be sent to you.
Daily Credit Limit*
Minimum = $200.00
Monthly Credit Limit*
Purchase Codes*

Guarantee & Indemnity
a)            The Guarantor acknowledges and represents that they received and understood our advice that they should seek independent legal advice before providing this guarantee. Despite our advice and/or the advice of their legal adviser, they have made their own informed decision to enter into this guarantee.

b) In consideration for us opening and providing a trading account to the Customer, the Guarantor guarantees all amounts of money of any nature that the Customer is, or may at any time in the future become, liable to pay us.

c)             The Guarantor indemnifies us against all costs, losses, expenses and liabilities (including legal expenses on a full indemnity basis) incurred by us at any time as a direct or indirect consequence of any amount that the Customer has failed to pay by the due date for payment. The Guarantor will pay upon demand, delivered by post to the Guarantor’s last known address, all amounts payable in relation to this indemnity.

d)            If there is a default by the Customer, we have full discretion to decide whether to enforce payment of the debt directly with the Customer, or whether we will pursue the Guarantor.

e)            If there is more than one Guarantor, this guarantee and indemnity is joint and several, and we can choose whether we will enforce it against only one, or more Guarantors, to remedy any default. There is no obligation on us to seek equal contributions from all Guarantors. Any Guarantor may be liable for the total amount payable to us and we are not obliged to pursue any liability equally amongst the Guarantors.

f)              This guarantee and indemnity will continue to operate until it is withdrawn by any Guarantor or released by us.

g)            This guarantee does not contain any obligation on us to disclose to the Guarantor any information regarding the Customer’s financial affairs, other than those provided by law. Privacy law prevents us from disclosing a Customer’s personal information to Guarantor.
Full Name of Guarantor*

PrefixFirst NameLast Name
* Guarantor must be the Applicant / Director
Signature*

Clear
* Use the left button on your mouse or touchpad and draw your signature in the signature box

Additional Comments:
Terms & Conditions:
Should be Empty:

Perks GOfuel Application Form

Personal Account Details

Business Account Details

Direct Debit Form

Fuel Card Details

Guarantee & Indemnity