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)
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