Order form for your Fuel Card

Please use the order form below to order your cards. Complete all the fields and do not forget to indicate your estimated average monthly consumption. We will get in touch with you within 5 days.

Company*:

Name* :

First name*:

Phone* :

E-mail address*:

Address*:

Postal code* (ex. L-1234) :
-

Town*:

VAT N°* (ex. LU-12345678):
-

Number of cards you would like to order* :
For more card please contact us.

Estimate of your monthly consumption (litres)*:

Vehicle brand and model*	Registration number*	Secret code* (1)	Mileage* (2)

Wishes to pay in cash at each visit, a paid invoice will be sent at the end of the month.*

The undersigned acknowledges having read the terms and conditions.

(*) Mandatory.
(1) To be completed: you can choose your own 4 figure PIN code.
(2) Tick the box if you want to receive mileage data.