Sales Connect - Fleet Card Application Form

Sales Representative

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UTM_SOURCE

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UTM_MEDIUM

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UTM_CAMPAIGN

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UTM_TERM

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UTM_CONTENT

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FBCLID

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MSCLKID

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GCLID

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CLIENTID

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UTMZ

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Referring Page

Sales Representative Name:**

Sales Representative Email Address:**

Business Details

Select Organisation Structure:**

Entity Name:**

Trading Name:**

ABN / ACN:**

Year Business Commenced:**

Business Physical Address:**

Business Postal Address:

Business Telephone:

Director / Owner Details

Director's First Name**

Director's Last Name**

Date of Birth:**

Driver's License No:**

Driver's License STATE:**

Director / Owner Residential Address

Unit / Level Number:

Street Number:**

Street Name:**

Street Type:**

Suburb / City:**

State:**

Post Code:**

Contact Person Details

Title:**

First Name:**

Last Name:**

Email:**

Mobile Phone:**

Office Phone:**

Job Title:**

Fuel Card Account Details

Planned Monthly Fuel Spend With Fleet Card:**

Number of Cards Required:**

Billing Cycle:**

Sales Reference:**

Preferred Payment Method**

Attach Signed Copy of Application and Vehicle Description Form:

Drop files here or

Max. file size: 50 MB.

Terms & Conditions

Please read the following carefully

Authority to Apply**

I confirm that the individual is authorized to apply for Fleet Card fuel cards by or on behalf of the sole trader/partners in the partnership/trustee for the trust to this application.

Declaration / Privacy Act**

I warrant that the information provided by or on behalf of the sole trader/partners in the partnership/trustee for the trust in this application is correct and authorise any person or organisation to provide Fleet Card with such information as may be required to establish their credit worthiness. Information provided above is specifically identified in the application process and can be referenced if the applicant wants to check accuracy.

Terms & Conditions**

I warrant that they have read and accepted Fleet Card Terms & Conditions

Privacy Policy**

I warrant that they have read and accepted Fleet Card Privacy Policy