APPLICATION FORM FOR FUEL CARD ACCOUNT

1. PROGRESS INDUSTRIAL ESTATE, STATION ROAD, ROGIET, NP26 3UE SALES@SEVERNFUELS.CO.UK (01291) 426900 (MAIN) (01291) 426901 (FAX) APPLICATION FORM FOR FUEL CARD ACCOUNT Name: ________________________________________ Address: ______________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Post Code: ___________________ Tel No: ___________________________ VAT Reg No: _________________ Company Reg No: __________________ E - Mail address: ________________________________ RDCO (if applicable): ____________________________ Type of Business: _________________ Market Sector: ___________________ Please state if limited company: ____________________ Please state if a Sole Trader: ______________________ Name and address of proprietor: ___________________________________________ _____________________________________________________________________ _____________________________________________________________________ Tel No: ________________________________ Please state if a Partnership: _________________________________ Partners name, addresses and telephone Numbers: 1) _______________________________ _________________________________ _________________________________ _________________________________ _________________________________ TEL No: __________________________ 2) _______________________________ _________________________________ _________________________________ _________________________________ _________________________________ TEL No: __________________________ YOUR LEADING FUELS AND LUBRICANTS SUPPLIER Registered in England No: 1560715, 1121025. Directors: MJ Mould, AG Mould

2. Please state if part of a group (if yes please give details): ____________________ __________________________________________________________________ __________________________________________________________________ Amount of Monthly Credit Sought: ______________________ Credit sought with (please tick): Severn Fuels Ltd Production Lubricants Ltd Name of Bank: _____________________________________ Account Number: ___________________________________ Sort Code: ________________________________________ Trade References Name: __________________________ Tel No: ___________________________ Name: __________________________ Tel No: ___________________________ Application signed on behalf of: ________________________________________ Signed and Accepted by: _______________________________ Print Name: ______________________ Position: __________________________ Date: ___________________________ STANDARD PAYMENT TERMS ARE BY DIRECT DEBIT 14 DAYS FROM DATE OF INVOICE Signing of this form confirms that we have read and accepted the Terms and Conditions of Sale. Every effort will be made to process this application as soon as possible and you will be notified in writing once this has been completed. Until such time, however, our supply terms are on either cash with order or cash on delivery basis. YOUR LEADING FUELS AND LUBRICANTS SUPPLIER Registered in England No: 1560715, 1121025. Directors: MJ Mould, AG Mould

3. PROGRESS INDUSTRIAL ESTATE, STATION ROAD, ROGIET, NP26 3UE SALES@SEVERNFUELS.CO.UK (01291) 42690 (MAIN) (01291) 426901 (FAX) Instruction to your Bank or Building Society to pay by Direct Debit Please fill in the whole form using a ball point pen and send it to: SEVERN FUELS / PRODUCTION LUBRICANTS PROGRESS INDUSTRIAL ESTATE, STATION ROAD, ROGIET, Nr NEWPORT, MONMOUTHSHIRE, NP26 3UE Originators Identification Number 9 8 0 6 1 6 Reference Number Name(s) of Account Holder(s) Instruction to your Bank or Building Society Please pay Severn Fuels / Production Lubricants Limited Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Severn Fuels Limited and, if so, details will be passed electronically to my Bank / Building Society. Bank / Building Society Account Number Branch Sort Code Name and full postal address of your Bank or Building Society Signature(s) To the Manager Bank/Building Society Address Postcode Date Banks and Build Societies may not accept Direct Debit instructions for some types of account Cut along dotted line and to be retained by the Payer The Direct Debit Guarantee • The Guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits • If there are any changes to the amount, date or frequency of your Direct Debit, Severn Fuels / Production Lubricants will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Severn Fuels / Production Lubricants to collect a payment, confirmation of the amount and date will be given to you at the time of the request • If an error is made in the payment of your Direct Debit, by Severn Fuels / Production Lubricants or your Bank or Building Society you are entitled to a full and immediate refund of the amount paid from your Bank or Building Society • If you receive a refund you are not entitled to, you must pay it back when Severn Fuels / Production Lubricants asks you to • You can cancel a Direct Debit at any time by simply contacting your Bank or Building Society. Written confirmation may be required. Please also notify us