Fields with an * (asterisk) are required, the form won't send without them.
Please read our terms and conditions before completing this form.

Your Details

Applicant's Full Legal Name*

Applicant's Date of Birth*

Your Email*

Street Number*
Street Name*
City*
Postcode*

Telephone*

Mobile

Your Company's Details

LTD CompanyIndividualSole TraderPartnershipOther

Trading as*

Nature of Business*

Years in Business*

If a Limited Liability Company

Address of Registered Office

Date of Incorporation

Incorporation No

Ownership

Full details of directors:
Name*
Address*
Contact number*

Name
Address
Contact number

Trade References*

Company
Contact Name
Contact Number
Account open since

Company
Contact Name
Contact Number
Account open since

Estimated Monthly Fuel Consumption (in litres)

Diesel
Diesel Storage Capacity

Unleaded 91
Unleaded 91 Storage Capacity

Premium 95
Premium 95 Storage Capacity

Lubricants
Lubricants Storage Capacity

Portal Sign Up

Complete this section if you want access to the online portal

Portal User Name
Portal Password

Account Type

Fuel CardBulk Fuel

Preferred Payment Method (paid by the 20th of each month)(if you want fuel cards, you must pay by direct debit)

Direct DebitDirect CreditCheque

Fuel Cards

Your Waitomo Fuel Card will provide you access to fuel at all Waitomo Fuel Stops and Mobilcard Acceptor sites. No card or transaction fees are applicable. If you require more than five cards please contact us on PH: 0800 922 123
All Waitomo Fuel Cards are Fuel and Oil Only
Please note that you MUST complete a Direct Debit Form if you wish to apply for a Waitomo Fuel Card

Card 1
Pin No

Card 2
Pin No

Card 3
Pin No

Card 4
Pin No

Card 5
Pin No

Direct Debit information:

Account Details

Account Name

Account Number

_

_

_

Information to appear on statements

Particulars
Code
Reference

I agree to the conditions of authority in relation to Direct Debit, as stipulated here and that I give authority until further notice, to debit my account with all amounts Waitomo Petroleum Limited (hereinafter referred to as the initiator) the registered Initiator of the listed Authorisation code (0614817), may Initiate by Direct Debit.

I warrant to Waitomo Petroleum Limited:
1: That the above information is to the best of my knowledge and belief, true and correct; and
2: That I have carefully read and agree to be bound by the terms and conditions; and
3: That I am duly authorised to make this credit account application on behalf of the applicant and of anyone duly authorised to enter into future contracts on behalf of the applicant