Fuel Card Facility
Trading Name of Applicant
Are you an existing Retail Decisions Merchant?
Existing ReD Merchant Number
Registered Business or Company Name
ACN Number
ABN Number
Place of Registration or Incorporation
Legal Status of Applicant's business
Street number and name
Suburb
State
Postcode
1. First Name
1. Surname
1. Street number and name
1. Suburb
1. State
1. Postcode
1. Home Telephone Number
2. First Name
2. Surname
2. Street number and name
2. Suburb
2. State
2. Postcode
2. Home Telephone Number
3. First Name
3. Surname
3. Street number and name
3. Suburb
3. State
3. Postcode
3. Home Telephone Number
Has electronic terminal capture by
Electronic Terminal Capture Number
Date to commence ( dd/mm/yyyy )
Telephone Number
Facsimile Number
E-mail Address
Payment options
Bank Name
Branch Name
Account Name
BSB Number
Account Number
Warranties: Each person signing below(a) warrants on behalf of the Applicant that they have authority to make this application on behalf of the Applicant and to the best of their knowledge and belief the above information is accurate and complete in all respects ; (b) acknowledges on behalf of the Applicant that if ReD accept the Applicant as a Merchant by signing and returning to the Applicant a copy of this document there will be an agreement between the Applicant and Merchant and ReD on the terms set out in the Merchant Agreement Terms and Conditions; and (c) agrees on behalf of the Applicant to be bound by those terms and conditions.
Signature
Date ( dd/mm/yyyy )
Print Name
Print Position
In the presence of (Signature)
You can either submit this form electronically or print it and send it to:(If you submit the form electronically there is no need to fill in the Signature field.)
Or fax it to:(03) 9274 9130
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or,
For information on our Merchant Rewards Program click here.
