subscription request

SUBSCRIPTION REQUEST
Document required to open an account
Reserved Axxès
Axxès customer no. :
Axxès contract no.:
Customer identification
Company name:
Surname/first name of the legal representative:
Company form:
NAF or NACE code:
EORI or VAT no°:
Address:
Town:
PO box:
Cedex:
Telephone:
Mobile:
Postcode:
Country:
Fax:
E-mail address of the legal representative*:
* all communications addressed to this e-mail address will have the same legal status as registered mail.
Additional contact** (optional)
o invoicing
o delivery o fleet manager
Surname/first name:
Job title:
Address:
PO box:
Town:
Cedex:
Country:
Telephone:
Mobile:
Fax:
Postcode:
E-mail address*:
** to add more contacts, go to the website customer area at www.axxes.eu
Mandatory documents to provide
Kbis, Lbis or registration application or association statutes less than 3 months old
Bank account details stating the IBAN and BIC numbers
Original to sign and return
I declare that I have read and expressly accept the Service Contract, and in particular the General Terms and Conditions of the
Axxès Services. I recognise that Axxès retains the right to refuse this application for the reasons given in their General Terms and
Conditions of Service, such as insolvency, cancellation of a previous contract for fraud or failure to pay etc.
In application of the French Data Protection Act no. 78/17 of 6 January 1978 (amended), the applicant is informed that the information provided on this application
form is required to enable the Subscription Request to be processed and that requests for information or correction can be sent to Axxès – 10/12 Bd Vivier Merle
69393 Lyon cedex 03 - France.
Date:
Signature [which must be preceded
by the handwritten comment in French
“Lu et Approuvé” (read and approved)]:
Signatory’s name:
Signatory’s job title:
Company stamp:
Your contact office
Tour Oxygène
10-12 boulevard Vivier Merle
69393 LYON CEDEX 03
FRANCE
+33 (0)4 26 29 75 20
+33 (0)4 26 29 75 22
[email protected]
1
AXXES
SAINT-MICHEL-DE-MAURIENNE
AXXES
SAINT-MARTIN-DE CRAU
Plateforme du Tunnel
CGAS - RN113
73500 MODANE
FRANCE
13558 SAINT-MARTIN-DE-CRAU
FRANCE
+33 (0)4 26 29 75 70
+33 (0)4 79 20 26 93
[email protected]
+33 (0)4 26 29 75 60
+33 (0)4 90 47 88 12
[email protected]
Axxès
SAS au capital de 7 500 000 € / N° de SIRET 482 930 385 00026 / APE 5221Z
Headquarters: Tour Oxygène – 10/12 Bd Vivier Merle – 69003 LYON -France
PR WEB 1214
AXXES LYON
www.axxes.eu
ORDER FORM
Heavy Goods
Vehicle Badge
Axxès customer no.:
Axxès contract no.:
Customer identification
Company name:
Choice of an offer of services
VIAXXÈS Offer
Microwave toll badge
VIAXXÈS SAT Offer
Satellite toll badge
VIAXXÈS SAT Manager Offer
Satellite toll badge
Tolls in
France, Spain,
Portugal and
Belgium
Customer
area
French
tolls
Remote
updates
X
X
X
X
X
X
X
X
X
X
X
X
X
Geolocation
Tick the offer
you want
❏
❏
❏
❏
X
Choice of paid-for options
Select paid-for options (for the Viaxxès SAT and Viaxxès SAT Manager offers only)
❏ TDT service (toll data transfer)
❏ EDI service (transmission of toll and GPS data)
For the prices of these offers and options, please refer to the current price list.
Access to discounts* on the French network
You wish to benefit from special commercial terms (discounts) for heavy goods vehicles on
❏ All motorway companies (includinf SAPN, SANEF, APRR)
❏ Only the mandatory motorway operating companies
Alternatively, select one or more motorway companies below for which access to these discounts is optional and provided for a fee.
French motorway companies:
COFIROUTE
ALIS (local discount)
SAPN
(Paris-Normandy motorways)
SANEF (motorways of north-eastern France)
APRR (Paris-Rhin-Rhône motorways)
CCIH (Tancarville and Normandy bridges)
❏ Mandatory
❏ Mandatory
❏
❏
❏
❏ Mandatory
Alienor
(Gascony motorway)
❏ Mandatory
ATMB (Mont-Blanc motorway and tunnel)
❏ Mandatory
SFTRF
❏ Mandatory
(Fréjus road tunnel)
AREA (Rhône-Alpes motorways)
❏ Mandatory
ESCOTA (Estérel and Côte d’Azur motorways)
❏ Mandatory
❏ Mandatory
❏ Mandatory
❏ Mandatory
ASF (motorways of southern France)
ALIS (A28)
ARCOUR (A19)
To access discounts on motorways in Spain operated by the ABERTIS group, you need to register your vehicles on the website
www.autopistas.com.
For other motorways on the Spanish network, you are registered automatically.
* The specific commercial conditions for France and Spain are available in the website’s customer area at www.axxes.eu.
1
www.axxes.eu
PR WEB 1214
Access to discounts* on the Spanish network
Toll badge order
Vehicle
Please provide the plate numbers and the requested information about the vehicles for which you are ordering toll badges.
Country
Euro
Emission
class**
Class 3
PLATE NO.
Class 4
= 2 axles
Choice of
an offer of
services
= 3 axles and more
(total number of axles
for each
vehicle
1
-
2
-
3
-
4
-
5
-
6
-
7
-
8
-
9
-
10
-
11
-
12
-
13
-
14
-
15
-
** For EEV vehicles, enter Euro 15 or EEV.
Mandatory documents
Registration certificate for each vehicle.
Original to sign and return
I declare that I have read and expressly accept the Service Contract, and in particular the General Terms and Conditions of the Axxès Services. I recognise
that Axxès retains the right to refuse this application for the reasons given in their General Terms and Conditions of Service, such as insolvency,
cancellation of a previous contract for fraud or failure to pay etc.
In application of the French Data Protection Act no. 78/17 of 6 January 1978 (amended), the applicant is informed that the information provided on this application form
is required to enable the Subscription Request to be processed and that requests for information or correction can be sent to Axxès – 10/12 Bd Vivier Merle 69393 Lyon
cedex 03 - France.
Date :
Signature [which must be preceded
by the handwritten comment in French
“Lu et Approuvé” (read and approved)]:
Signatory’s name:
Signatory’s job title:
Company stamp:
Your contact office
Tour Oxygène
10-12 boulevard Vivier Merle
69393 LYON CEDEX 03
FRANCE
+33 (0)4 26 29 75 20
+33 (0)4 26 29 75 22
[email protected]
2
AXXES
SAINT-MICHEL-DE-MAURIENNE
AXXES
SAINT-MARTIN-DE CRAU
Plateforme du Tunnel
CGAS - RN113
73500 MODANE
FRANCE
13558 SAINT-MARTIN-DE-CRAU
FRANCE
+33 (0)4 26 29 75 70
+33 (0)4 79 20 26 93
[email protected]
Axxès
SAS au capital de 7 500 000 € / N° de SIRET 482 930 385 00026 / APE 5221Z
Headquarters: Tour Oxygène – 10/12 Bd Vivier Merle – 69003 LYON -France
+33 (0)4 26 29 75 60
+33 (0)4 90 47 88 12
[email protected]
PR WEB 1214
AXXES LYON
www.axxes.eu
SEPA DIRECT DEBIT AUTHORISATION
Axxès customer no.:
Axxès contract no.:
By signing this mandate form, you authorise (A) Axxès to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Axxès
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your
agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your
account was debited.
Account
Creditor
Name:
Axxès
Tour Oxygène - 10-12 bd Vivier Merle
69393 Lyon Cedex 03 - FRANCE
Address:
Postcode:
City:
Country:
IBAN:
BIC:
Payment: Recurrent
Signed in:
Date:
Signature:
Area reserved for the creditor’s use
The unique mandate reference will be quoted on your next Axxès invoice.
Creditor’s SEPA identifier: FR05ZZZ503932
Mandatory documents to provide
Bank account details stating the IBAN and BIC numbers.
1
Axxès
SAS au capital de de 7 500 000 € / N° de SIRET 482 930 385 00026 / APE 5221Z
Headquarters: Tour Oxygène – 10/12 Bd Vivier Merle – 69003 LYON -France
PR WEB 1412
Form to be returned with your bank account details to your sales office
www.axxes.eu