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Apply Online
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Apply Online
Simply complete ALL the details and submit the form below.
We will then contact you to confirm financial details to complete your application.
Or, click here to download a form which you can print and send back to us.

1. COMPANY DETAILS
Company/Name to be embossed on all your cards
(Maximum 19 characters INC blank spaces)

Company Name         Telephone
Address 1         Mobile
Address 2         Fax
Town/City         Contact Name
County         Job Title
Postcode         Company Website
Time at this address         Email
Company Reg No. (if applic)        
We may occasionally send you information by e-mail which you may find useful. We will not pass your details to any third party. Please check the box if you DO NOT wish to be contacted via e-mail.

If not a limited company, please complete the following:

Proprietor's/Partners' Name(s)
Home Address
Postcode


2. FUEL REQUIREMENTS
Estimated Monthly Usage (by expenditure or volume, minimum £500 per month)
How many diesel vehicles do you have?
How many petrol vehicles do you have?
Do you have bulk fuel delivered to your premises?
  Yes         No
Do you purchase lubricants?
  Yes         No


3. CARD DETAILS
How many cards do you require?             Do you want mileage recorded?    
  Yes         No
      (Standard Charge £6 per card)


Please list the name of the driver or vehicle registration you require on each card.

Also select the purchase option required for the driver/vehicle (optional):
60 - Diesel only
61 - Fuels only
62 - Fuels & lubricants
63 - Fuels, lubricants & car wash
64 - Fuels, lubricants, car wash & vehicle related goods/services

  Driver Name Registration Number Purchase Option
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

If you require more than 10 cards, these details can be confirmed when we contact you.
4. ACCOUNT MANAGEMENT
Would you like to register for Online Account Management?   Yes      No 
Invoices are normally sent by e-mail.
If you would prefer to receive your invoice by post, please click here		 Send By Post

5. TERMS AND CONDITIONS
I hereby agree to accept the Countrywide Fuel Cards terms and conditions of trading,
and understand that a copy of these is available upon request.


6. DATA PROTECTION ACT 1998
The information which you provide may be disclosed to a licensed credit reference agency
which will retain a record of the search. It may be used by other lenders in assessing
applications from you and other members of your household and for occasional debt
tracing and fraud prevention.


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