FORMULAIRE DE DEMANDE POUR LA CARTE FORAX

FORMULAIRE DE DEMANDE POUR LA CARTE FORAX
Les champs marqués par (*) sont facultatifs
Coordonnées Primaires Nom
Prénom
Fonction (*)
Numéro de Protocole
TéL
GSM
Fax (*)
E-MAIL
Mr
Mme
Melle
Ambassade / Organisation
DéPARTEMENT (*)
Rue / Numéro
Code Postal
Ville
Contact Secondaire (*)
Nom
Prénom
Fonction (*)
TéL / GSM
E-MAIL
Mr
Mme
Melle
Précision lieu de la station sur facture:
Oui
Non
Fax (*)
Consommation
Usage Officiel
Usage Individuel
Paiement par virement bancaire Pour Usage Officiel: si vous préférez payer par virement bancaire (pas de prélèvement automatique), cochez cette case
au lieu de remplir le Mandat de domiciliation SEPA.
Mandat de domiciliation récurrente SEPA
Le soussigné prie la société Forax SA, Frankrijklei 150, 2000 Anvers, Belgique, d’encaisser toutes les factures sur une base hebdomadaire, et ceci à partir de ce jour et
jusqu’à révocation expresse. En signant ce formulaire de mandat, j’autorise (A) Forax SA, N° Créancier BE81SHL0829092949, Frankrijklei 150, 2000 Anvers, Belgique à
envoyer des instructions à ma banque pour débiter mon compte, et (B) ma banque à débiter mon compte conformément aux instructions de FORAX.
Nom du débiteur
BIC
IBAN
Rue / Numéro
CODE POSTAL
Ville
Pays
Référence du Mandat: Votre Numéro de Client FORAX sera utilisé comme référence. Vous trouverez ce Numéro sur la Lettre de Bienvenue et sur vos factures.
Signature
En signant ce formulaire, je marque mon accord avec les conditions générales de vente de la carte FORAX. J’autorise Forax à utiliser mes données
personnelles pour l’envoi de mailings. Je confirme que les informations ci-dessus sont certifiées exactes. Je m’engage à informer Forax de tout
changement de mes coordonnées ou de mes données bancaires.
DATE (DD/MM/YYYY)
LIEU
/
/
Signature
Forax | PB 56 | 2900 Schoten | Belgium | Office +32 2 66 99 444 | Fax +32 2 66 99 441 | BE 0829 092 949
[email protected] | www.forax.eu
General Terms and Conditions
These General Terms & Conditions will govern all transactions performed
with the Forax Card (hereinafter: “The Card(s)”) between Forax NV, with
its corporate seat in 2000 Antwerpen, at Frankrijklei 150, and its customers, (hereinafter: “The Customer”), in so far as Parties have not explicitly
provided otherwise.
1 This contractual commitment resulting from the signature of the Application Form will be for an indefinite period of time, its effective date being
the date the Customer signs the Application form.
2 Forax will be entitled to terminate the contract without prior notice,
should the rules and regulations set by the government, change in a way,
that the fulfillment of the benefits of the Customer are no longer possible.
3 The Forax Card will be strictly personal, non-transferable and obtainable
only from Forax.
4 The Card(s) will be issued only to persons whose job description
qualifies them to tax-free fuel. Part of the application process being that
Forax will verify the legitimacy of the application on the basis of the 136F
form submitted by applicant. A Forax Fuel card will always be attached
to an approved 136F. Cards will ‘expire’ or be ‘stopped’ when the related
136F expires or when the volume has been used up.
5 The Card(s) will be legal tender for purchasing fuel at all Shell service
stations in Belgium.
6 The Forax website and its services is accessible by means of a user
ID and password given by Forax, by electronic mail, either on the
Customer’s demand or on proposal of Forax. The user ID and password
are confidential. The Customer is responsible for consequences of any
abuse of these data. For security reasons, access to the site may be
invalidated after several erroneous attempts. Forax reserves the right
to suspend the Customer’s access to the site in case of fraudulent use
or attempted fraudulent use of this access. The termination of this
contract entails termination of the access to the site.
7 Forax cannot be held liable for any temporary or definitive unavailability
of the products on one or more gas stations. Forax will be allowed to
modify the available fuel products at any time, and this may result in a
new Card being issued. Forax will not be held responsible for any
defective product delivered at the gas station.
8 The Customer remains responsible for his/her Card(s) and the use
thereof until card expiry. Blocked Cards and Cards that have expired
should be cut in two by the Customer and returned to Forax.
9 The Customer undertakes to inform Forax in writing and prior to the
change about name or address changes, bank account number changes,
and any changes that may impact his/her right to be qualified for tax-free
fuel purchases.
10In case of Direct Debit, acquisition of the Card(s) will be subject to
the Customer agreeing that purchases made with The Card(s) shall
be paid via his bank account through automatic debit. Forax will notify
the Customer for every Direct Debit. The notification will be sent at
the latest on the day on which the bank will be instructed to debit the
Customer’s account. In the case of SEPA Direct Debits, the Customer
has the right to request a refund from his bank according to the
conditions specified in his agreement with it. All refund requests must
be submitted within eight weeks of the date on which the Customer’s
bank account was debited.
11 When no timely payment is received, then Forax will be entitled to
block the Card(s) with immediate effect. If upon subsequent reminder
the customer does not pay, then Forax reserves the right without
sending any notification to institute judicial collection. The relevant
costs will be for the Customer and are nominally set at 10% of the
receivable or a minimum of 75 euro. Moreover, legal interest will be
claimed from the moment that payment could not be executed.
12 The customer will receive a periodical invoice in electronic PDF-format
via Forax’s e-Invoicing system. Upon request, the customer can receive
the invoice in hard copy.
13 For each Card a unique and secret Personal Identification Number (‘PIN
Code’) will be issued to the Customer. This PIN Code will differ per
Card. The Customer is responsible for the correct use of the Card and
the PIN Code. The Customer will not keep his/her card and PIN Code
together. The Customer will keep his/her PIN Code secret, will not write
it down and will not tell the PIN Code to other people. The Customer
shall never write his secret PIN Code down on the Card.
14 The Customer will have custody over the Card(s) that has/have been
assigned to him. To this effect the Customer shall take any measures that
may be useful to prevent the Card(s) from being lost, stolen or damaged.
The Customer will be responsible for the use of the Card(s) that has/
have been assigned to him. The Customer cannot dispute transactions
for which the PIN has been validated, even if the card was skimmed.
15In the event of theft or loss of a Card, the Customer undertakes
to immediately inform Forax via phone. Moreover, the Customer
has to confirm the theft or loss of a card in writing, specifying name,
reason for making the report, Card number (19 digits), date and hour
of the report. The suspension of the Card will be effective two (2)
business days after receipt by Forax of a written confirmation by the
Customer of the loss, theft or damage of the Card. Forax shall accept
no liability for costs or transactions executed with the Card that date
prior to the moment of the complete report of loss or theft.
16 Forax reserves the right to revoke / block the Card(s) in case of
non-compliance with these General Terms & Conditions, fraudulent
or abnormal use by the entitled party or a third party, non-payment
of the amounts due, or habitual insolvency of the Customer, and such
without any prior notification and without prejudice to any and all
claim for damages that Forax could be entitled to. All costs and
damage ensuing from fraudulent and abnormal use shall be for account
of the party entitled to the Card(s).
17 Force Majeure. In the event of force majeure, Forax has the right, at
its own option and without being liable for damages, to suspend the
performance of the contract, or to fully or partially dissolve this contract
without legal recourse, unless such measures are unjustified, taking in
to account the duration of the force majeure. For the purpose of this
agreement force majeure is understood to mean any circumstance
which Forax could not reasonably have taken in to account at the time
of the conclusion of the contract and as a result whereof the normal
performance of the contract can not be reasonably required by Forax,
such as, but not limited to, natural and environmental disasters, war,
threat of war, riots, strikes, partial or complete non-performance by
third party suppliers, raw materials or ancillary materials and/or energy,
government measures of any kind, transport problems, fire and other
calamities at Forax or at its suppliers. The non-imputable and inevitable
character of the aforementioned circumstances is presumed.
18 Forax may at any time assign all of its rights and obligations (or part
thereof) within the terms of the present contract to any branch or
related company of the Forax group or any third party. The Customer
undertakes not to assign or transfer, in any form whatsoever, all of its
rights and obligations (or part thereof) resulting from this contract.
19This contract shall be subject to the laws of Belgium. In case of disputes,
the courts in Brussels shall be exclusively competent.
20 Forax reserves the right to amend the General Terms & Conditions
at any time, in which event the Customer will be notified via corre­
spondence or via statement on the invoice. Any use of the Card, five
(5) business days after the notice of modification of the General Terms
and Conditions, will entail acceptance thereof without any reservations.
21 All executed transactions will be invoiced to the Customer by Forax in
its name and for its account. The applicable price can be checked by the
Customer on a daily basis at simple Customer request. Fuel transactions
will be invoiced without VAT and taxes as long as customs endorsement
is received. Fuel transactions for which Forax does not receive customs
approval will be invoiced including taxes.
22 Any comments with reference to invoices or transaction statements
must be reported in writing within 30 days. No comment or challenge
will be accepted upon expiration of this period.
23 Forax shall accept no liability for the consequences of the Customer’s
inability to use the Card(s) due to a malfunction or temporary defect
in or inexpert use of the Card Readers. Nor when the Card was
damaged or withheld by the Card Reader due to such a cause.
When appropriate, the Customer will be required to immediately
contact the Forax Service Center.
24 Protection of personal data. By virtue of the laws on privacy
(Belgian Act of 8 December 1992, on the protection of privacy in
respect to the processing of personal data – M.D., 18 March 1993)
the Customer is informed of the fact any personal data regarding
himself, will be processed and stored by Forax N.V., Frankrijklei 150,
2000 Antwerpen – Belgium. These data are necessary for the
execution of the contract to which the Customer is a party or
for the execution of pre-contractual measures that may be taken
on his request. The Customer authorizes Forax N.V. to use those
data, including his email address, and therefore may receive commercial
offers from Forax N.V. The Customer is entitled to object, free of
charge and up on request addressed to Forax N.V. to the use thereof
for the effect of direct marketing. The Customer has a right of access
and rectification with respect to the personal data regarding himself,
and to this effect may address Forax N.V. at any time.
DO YOU HAVE OTHER QUESTIONS ABOUT THE FORAX
CARD? CALL 02/66 99 444
FORMULAIRE DE DEMANDE DE CARTE
Coordonnées Primaires NOM
Prénom
TéL / GSM
Ambassade / Organisation
Mr
Mme
Melle
N° de Client (pour Clients existants)
Merci d’indiquer ci-dessous les détails des cartes que vous souhaitez commander
Note: seuls les types de carburants mentionnés sur votre 136F seront facturés hors taxes.
Plaque
Type de Carburant d’Immatriculation
Facultatif: limite par carte
Pour relier vos cartes au volume
entier du quota sans limite spécifique
par carte il suffit de remplir le
champs ‘Volume entier du Quota’
CARte 1
Diesel
Essence
Litres
CARTE 2
Diesel
Essence
Litres
CARTE 3
Diesel
Essence
Litres
CARTE 4
Diesel
Essence
Litres
CARTE 5
Diesel
Essence
Litres
CARTE 6
Diesel
Essence
Litres
CARTE 7
Diesel
Essence
Litres
CARTE 8
Diesel
Essence
Litres
CARTE 9
Diesel
Essence
Litres
CARTE 10
Diesel
Essence
Litres
CARTE 11
Diesel
Essence
Litres
CARTE 12
Diesel
Essence
Litres
CARTE 13
Diesel
Essence
Litres
CARTE 14
Diesel
Essence
Litres
CARTE 15
Diesel
Essence
Litres
CARTE 16
Diesel
Essence
Litres
CARTE 17
Diesel
Essence
Litres
CARTE 18
Diesel
Essence
Litres
CARTE 19
Diesel
Essence
Litres
CARte 20
Diesel
Essence
Litres
Volume entier du Quota
Litres
Important: doit correspondre au volume du Quota sur le 136F
Litres
Besoin d’aide?
Appelez le Centre de Services Forax en direct au 02 / 66 99 444
Remarques: Forax | PB 56 | 2900 Schoten | Belgium | Office +32 2 66 99 444 | Fax +32 2 66 99 441 | BE 0829 092 949
[email protected] | www.forax.eu