EG Fuel Card Application Reseller Fill in and submit the business application form below for assessment Sales RepresentativeUTM_SOURCEUTM_MEDIUMUTM_CAMPAIGNUTM_TERMUTM_CONTENTFBCLIDMSCLKIDGCLIDCLIENTIDutmzReferring PageSales Representative Name:**Sales Representative Email Address:** Outsource partner:**(please select) ↓PLGBusiness DetailsSelect Organisation Structure:**(please select) ↓Sole TraderPartnershipTrustCompanyGovernment AgencyIncorporated SocietyEntity Name:**Trading Name:**ABN / ACN:**Year Business Commenced:**Business Physical Address:**Business Postal Address:Business Telephone:Director / Owner DetailsDirector's First Name**Director's Last Name**Date of Birth:** Date Format: DD slash MM slash YYYY Driver's License No:**Driver's License STATE:**Director / Owner Residential AddressUnit / Level Number:Street Number:**Street Name:**Street Type:**(please select) ↓AccessAlleyAlleywayAmbleAnchorageApproachArcadeArteryAvenueBankBasinBayBeachBeltBendBlockBoulevardBraceBraeBreakBriarsBridgeBroadwayBrowBypassBywayCausewayCentreCentrewayChaseCircleCircletCircuitCircusCloseColonnadeCommonConcourseCopseCornerCorsoCourseCourtCourtsCourtyardCoveCrescentCrestCroftCrossCrossingCrossroadCrosswayCruisewayCul-de-sacCuttingDaleDellDeviationDipDistributorDownsDriveDrivewayEastEdgeElbowElmEndEntranceEsplanadeEstateExpresswayExtensionFairwayFire TrackFiretrailFlatFlatsFollowFootwayForeshoreFormationFreewayFrontFrontageGapGardenGardensGateGatesGladeGlenGrangeGreatGreenGroundGroveGullyHavenHeadHeathHeightsHighroadHighwayHillHubInterchangeIntersectionIslandJunctionKeyLandingLaneLanewayLargoLeesLineLinkLittleLockLookoutLoopLowerMallMeadMeadowsMeanderMewsMileMotorwayMountNookOutlookParadeParkParklandsParkwayPartPassPathPathwayPiazzaPlacePlateauPlazaPocketPointPointsPortPromenadePursuitQuadQuadrangleQuadrantQuayQuaysRambleRampRangeReachReserveRestRetRetreatReturnRideRidgeRidgewayRight of WayRingRiseRiverRiverwayRivieraRoadRoadsRoadsideRoadwayRondeRosebowlRotaryRoundRouteRowRueRunService WayShopingSidingSlopeSoundSpurSquareStairsState HighwayStepsStraitStrandStreetStripSubwaySummitTailingsTarnTerraceThoroughfareTollwayTopTorTowersTrackTrailTrailerTramwayTriangleTrunkwayTunnelTurnUnderpassUpperValeValleyViaductViewVillageVillasVistaWadeWalkWalkwayWatersWayWestWharfWoodWyndYardSuburb / City:**State:**(please select) ↓ACTNSWNTQLDSATASVICWAPost Code:**Contact Person DetailsTitle:**(please select) ↓Ms.MissMrs.Mr.First Name:**Last Name:**Email:** Mobile Phone:**Office Phone:**Job Title:**Fuel Card Account DetailsPlanned Monthly Fuel Spend With FuelLynk:**Number of Cards Required:**Billing Cycle:**(please select) ↓WeeklyFortnightlyMonthlySales Reference:**(please select) ↓FLK_EG_Single_OB_5-2_ZeroFLK_EG_Single_OB_6-2_0.99-2.99Preferred Payment Method**(please select) ↓Direct CreditDirect DebitAttach DD / Financials (if required): Drop files here or Terms & ConditionsPlease read the following carefullyAuthority to Apply** Your call will be recorded and will be retained for legal purposes. You are about to form a legally binding contract with lynked Solutions Pty Ltd on behalf of (STATE COMPANY NAME) Do you warrant that you are the sole director or proprietor of (STATE COMPANY NAME) , or that you have the authority of the directors of (STATE COMPANY NAME) to enter into this contract? 2. Please state your full name, and the position which you hold at (STATE COMPANY NAME) , or the capacity in which you are authorised to represent (STATE COMPANY NAME) . Declaration / Privacy Act** Do you warrant that the proprietors, partners or directors of (STATE COMPANY NAME) , have confirmed that the information you have given or are about to give is correct, and they authorise any person or organisation, including Dun and Bradstreet, to provide Lynked Solutions Pty Ltd with such information as may be required to establish their personal credit worthiness and the credit worthiness of (STATE COMPANY NAME) . Terms & Conditions** Our terms and conditions explain important information on card usage, fees, how we communicate with you and other information relevant regarding your fuel card. Do you confirm that you accept LYNKED SOLUTIONS PTY LTD Terms and conditions which are publicly available on our website WEBSITE. 2. A copy of these Terms and conditions will also be emailed once your application is submitted for review by our credit team. 3. Do you understand that should this application be approved use of the fuel cards is deemed to show (STATE COMPANY NAME) acceptance of Lynked Solutions's Terms and Conditions? 4. My name is (STATE NAME) and do you agree that today you have been offered NUMBER Cards. You understand that: you have a card fee of Card Fee. Your fuel discount is XX cents per litre. All Fees and fuel discounts are governed by our terms and conditions. Direct Debit Authority** 1. Can you please advise the name and bank account number which funds should be direct debited from: 2. Are you an authorised signatory of this account? 3. Do you confirm that you understand that you are entering into a direct debit contract with LYNKED SOLUTIONS PTY LTD on behalf of business name.