Prepaid Account Application

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Company name hidden:
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This is a Prepaid Fuel account, where funds are added to the account in advance to be used by the fleet.
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Company Name:* This field is required.
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Application Date:* This field is required.
Date
Day
Month
Year
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First name of applicant:* This field is required.
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Last name:* This field is required.
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Email of Applicant:* This field is required.
example@example.com
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Email for Monthly Statements:* This field is required.
example@example.com
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Mobile Number of the Account Holder:* This field is required.
Area Code
Phone Number
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Job Title:* This field is required.
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Street Address* This field is required.
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Suburb:* This field is required.
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Postcode:* This field is required.
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ABN* This field is required.
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Shop* This field is required.Any product sold in-store (excludes cigarettes)
YESNO
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Cigarettes* This field is required.Sold in-store
YESNO
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Carwash* This field is required.Any product sold in-store (excludes cigarettes)
YESNO
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Gas* This field is required.Any product sold in-store (excludes cigarettes)
YESNO
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ULP 91* This field is required.Sold in-store
YESNO
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PULP 95* This field is required.Sold in-store
YESNO
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PULP 98* This field is required.Sold in-store
YESNO
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Diesel Gold* This field is required.Sold in-store
YESNO
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AdBlue* This field is required.Sold in-store
YESNO
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Contact name for courtesy "low funds" call:* This field is required.
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Phone Number:* This field is required.
Please enter a valid phone number.
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Anticipated Monthly Spend:* This field is required.
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Low Funds Call (Amount):* This field is required.
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Select your preferable payment method:* This field is required.
Please Select
Please Select
Deposit
Eftpos
Cash
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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
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REGO
Vehicle Brand (e.g. Ford)
Colour
Vehicle 01
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Vehicle 02
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Vehicle 03
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Vehicle 04
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Vehicle 05
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Vehicle 06
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Vehicle 07
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Vehicle 08
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Vehicle 09
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Vehicle 10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Vehicle 01
Vehicle 02
Vehicle 03
Vehicle 04
Vehicle 05
Vehicle 06
Vehicle 07
Vehicle 08
Vehicle 09
Vehicle 10
REGO
Row 0, Column 0
Vehicle Brand (e.g. Ford)
Row 0, Column 1
Colour
Row 0, Column 2
REGO
Row 1, Column 0
Vehicle Brand (e.g. Ford)
Row 1, Column 1
Colour
Row 1, Column 2
REGO
Row 2, Column 0
Vehicle Brand (e.g. Ford)
Row 2, Column 1
Colour
Row 2, Column 2
REGO
Row 3, Column 0
Vehicle Brand (e.g. Ford)
Row 3, Column 1
Colour
Row 3, Column 2
REGO
Row 4, Column 0
Vehicle Brand (e.g. Ford)
Row 4, Column 1
Colour
Row 4, Column 2
REGO
Row 5, Column 0
Vehicle Brand (e.g. Ford)
Row 5, Column 1
Colour
Row 5, Column 2
REGO
Row 6, Column 0
Vehicle Brand (e.g. Ford)
Row 6, Column 1
Colour
Row 6, Column 2
REGO
Row 7, Column 0
Vehicle Brand (e.g. Ford)
Row 7, Column 1
Colour
Row 7, Column 2
REGO
Row 8, Column 0
Vehicle Brand (e.g. Ford)
Row 8, Column 1
Colour
Row 8, Column 2
REGO
Row 9, Column 0
Vehicle Brand (e.g. Ford)
Row 9, Column 1
Colour
Row 9, Column 2
1 of 10
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Choose a unique 4-digit PIN for your card(s)Do not use your date of birth or a sequence like 1234. You can change it anytime via the APW portal.
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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.
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Signature:* This field is required.
Clear
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