Prepaid Account Application

449 Great Western Hwy, Wentworthville, 2145
ABN: 11 620 023 592
Prepaid Account - Application Form
Company name hidden:
This is a Prepaid Fuel account, where funds are added to the account in advance to be used by the fleet.
Company Name:*
Application Date:*

DayMonthYear
Date
First name of applicant:*
Last name:*
Email of Applicant:*
example@example.com
Email for Monthly Statements:*
example@example.com
Mobile Number of the Account Holder:*
Please enter a valid phone number.
Job Title:*
Street Address*
Suburb:*
Postcode:*
Please specify products allowed to be used on this account:*

ShopUnleaded 91Premium 95Premium 98Diesel GoldCarwash PlatinumCarwash PremiumCarwash DeluxeCarwash ExpressOilsGasEverything
Contact Details and Amount
Contact name for courtesy "low funds" call:*
Phone Number:*
Please enter a valid phone number.
Anticipated Monthly Spend:*
Low Funds Call (Amount):*
Payment Method
Select your preferable payment method:*
For Direct Deposit: BSB: 082-490 - Acc: 23 283 4565 - Please add your Account Name as bank reference. Funds transferred are applied to your account once cleared.

For Credit Cards: 2.5% surcharge
Authorised Acount Users

Customer Acknowledgement
By submitting this form I understand that this account is prepaid only, and no form or credit will be extended for any reason.

Accounts that have reached their limit will require a top-up, as staff cannot extend accounts passed their credit balance.

I agree to the use of this information for the management of your account with APW only.
Signature:*

Clear
Should be Empty:

Prepaid Account - Application Form