08 8367 2000
[email protected]
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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 Mogas Regional Pty Ltd ABN 79 111 402 110 (Mogas) who wish to establish a Credit Account for Bulk Fuel with Mogas or who wish to be issued a Mogas FuelCard. Please contact us on (08) 8367 2000 for the full Terms and Conditions relating to the supply of Products by Mogas, the use of a Credit Account or Bulk Facility and the terms of use of FuelCards issued by Mogas (Standard Terms). The Standard Terms are also available on our website (www.mogasregional.com.au).
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 set out below.
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 Mogas in accordance with the Terms and Conditions and submit the following confidential information for this purpose only:
Location and contacts:
(Required)
Pt Augusta
Pt Lincoln
Wudinna
Riverland
South East SA
Kangaroo Island
Adelaide
Kununurra
Darwin
Katherine
Alice Springs
Other
Sales Contact
Select All
Other (if selected)
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)
Credit Limit for FuelCard $
(Required)
Credit Limit for bulk fuel $
(Required)
PULP (litres)
ULP (litres)
Diesel (litres)
LPG (litres)
Lubes (litres)
Please note that Mogas may choose to open a Credit Account for Bulk Fuel or Fuel Card with a Credit Limit lower than that requested by the Applicant, at Mogas’ sole discretion.
FuelCard fees & payment terms
A standard card fee of $5.50 per month shall be payable by the Applicant in respect of each FuelCard issued by Mogas. 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 Mogas.
Mogas will issue to the Applicant a statement at the end of each month showing the total amount owing by the Applicant to Mogas. This amount must be paid by the Applicant within 21 days of the date of the statement.
Where applicable, payments 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)
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