General registration form for Motorway Cards and Devices

To obtain cards and/or devices, please provide the information indicated in this registration form to the local euroShell representative, who then forwards the applications to FDE. Please use block letters.

Company name:

Address:

Postal code and town:

Telephone: Telefax: E-mail: ______

Company activity: Transport Dispatch/Coach Others

VAT no: UID no: Contact person:

Postal address:

I hereby request to receive the following number of cards/devices for payment of tolls:

France ______Fréjus cards – see Order Form below

Time of delivery around 3 – 4 weeks

Italy ______Viacards. Time of delivery around 2 - 3 weeks

______Telepass devices – see Order Form and Application Form for FDE Consortium

below. Time of delivery approx 2 – 3 weeks.

Companies established in an EU country which carry out transport of goods can obtain a refund of part of the motorway tolls paid with Viacard/Telepass by entering a consortium. By entering the FDE CONSORTIUM customers will always receive the highest available rebates (up to approx. 13%). If you are interested, please fill in and send us the enclosed registration form. Please note that the registration fee of 5 euro is paid by FDE.

Spain ______Servisa cards. Time of delivery around 2 weeks

______Via T devices – see Order Form below. Time of delivery around 4 – 6 weeks

Portugal ______Via Verde devices – see Order Form below. Time of delivery around 4 – 6 weeks

Denmark, Norway, Sweden

______Brobizz devices – see Order Form below. Time of delivery around 2 weeks

Date Signature and company stamp

To be filled in by Shell:

Issuer code (e.g. 7077) _7_ _0_ _7_ _7_

Country code _3_ _0_ Release code _8_

Customer number ______Customer check digit __

Date Signature of Shell

ORDER FORM TELEPASS

TELEPASS ORDER

License plate no. Nationality Euro type

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

______

Place, Date Company stamp and signature

Richiesta di adesione a FDE CONSORTIUM

Spett.Le

FDE CONSORTIUM

Viale Brigata Mantova 3

46100 Mantova

La scrivente ditta/società …………………………………………………...... ,

corrente in……………………………., via………..……………...... ,n.….….,nella

persona del proprio titolare/rappresentante, il sig………….…...... ;

nato a……………..……………………….il…….…………………., residente a…… ………………...., in via ………….…………………., n...…., c.f………………………………………...,

CHIEDE

di essere ammessa a far parte di FDE CONSORTIUM.

Allo scopo, la scrivente :

- dichiara di essere a conoscenza di tutte le disposizioni dello Statuto sociale e degli eventuali regolamenti, e di accettarle integralmente;

- si impegna a versare l’importo di 5,00 Euro corrispondente ad una parte della quota sottoscritta entro 30 giorni dalla ammissione al Consorzio ;

- si impegna a far pervenire al consorzio entro 30 giorni dalla presente richiesta la copia autenticata della licenza comunitaria.

Luogo:………………………………

Data :……………………………….

Per la ditta/società

Il rappresentante, sig………...... ………………

BANKING DETAILS FOR ITALIAN REBATE

Name and address of the Bank: ______

SWIFT/BIC Code: ______

IBAN Code: ______

Date: ______Company stamp and Signature:______

OPOZORILO:

Za včlanitev v FDE konzorcij je potrebno pripraviti in poslati sledeče dokumete:

·  izpolnjen italijanski obrazec “Richiesta di adesione a FDE CONSORTIUM”

·  veljavno kopijo osebnega dokumetna pospisnika podjetja

·  kopijo veljavne EU LICENCE (izdane s strni obrtne oz gospodarske zbornice)

2