Badge Heavy Goods Vehicle

ORDER FORM
Badge
Heavy Goods Vehicle
Axxès customer no.:
Axxès contract no.:
Customer identification
Company name:
Choice of an offer of services
Select the offer of services you would like and the options that interest you.
VIAXXÈS
Offer
VIAXXÈS SAT
Offer
VIAXXÈS SAT Manager
Offer
Microwave toll badge
Satellite toll badge
Satellite toll badge
Customer area
Customer area
Customer area
French tolls
Tolls
Tolls
in France, Spain,
Portugal and Belgium
Tolls
in France, Spain, Portugal and Belgium
in France, Spain, Portugal and Belgium
Heavy goods vehicle transit toll
Heavy goods vehicle transit toll
Remote update and modification
services
Remote update and modification
services
Toll
+ OPTIONAL
(data transfer)
EDI
(GPS + TOLL DATA)
Geolocation and fleet management
Viaxxès SAT Manager
Toll
❏ I subscribe to the Viaxxès offer* with
+ OPTIONAL
(data transfer)
or ❏ French tolls (all motorway operating companies)
❏ Tolls (interoperability France + Spain + Portugal + Belgique)
EDI
(GPS + TOLL DATA)
❏ I subscribe to the Viaxxès SAT offer* with
I add in paying option ❏ EDI service or
❏ Transmission of Toll data presentation
or
❏ Transmission of Toll data presentation
❏ I subscribe to the Viaxxès SAT Manager offer* with
I add in paying option ❏ EDI service For smoother administration, we recommend completing a separate order form for each offer of services you want.
For details of the offers of and options services prices, please refer to the current price list.
*
Generals terms and conditions of Axxès services available on www.axxes.fr
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Information on the French network
Access to discounts on the French network
You wish to benefit from special commercial terms (discounts) for heavy goods vehicles on
❏ All motorway operating companies
Alternatively, select one or more motorway companies below for which access to these discounts is optional and
provided for a fee
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 (Fréjus road tunnel)
❏ Mandatory
AREA (Rhône-Alpes motorways)
❏ Mandatory
ESCOTA (Estérel and Côte d’Azur motorways)
❏ Mandatory
❏ Mandatory
❏ Mandatory
❏ Mandatory
ASF (motorways of southern France)
ALIS (A28)
Mandatory documents
Registration certificate for each vehicle.
CEMT certification or COC because the euro pollution class is required.
If you wish make a declaration for the heavy goods vehicle transit toll, without this document your vehicle will be declared with
Euro pollution class 0.
Taxpayer susbscriber declaration for the heavy goods vehicle transit toll
If you select the Viaxxès SAT or Viaxxès SAT Manager offer, the toll badge includes the heavy goods vehicle transit toll
service (once your application has been approved by the state’s representative). You can declare your vehicles for
heavy goods vehicle transit toll. To do this, you need to return the signed SHT mandate and the supporting
documents to your sales office (see the document “Taxpayer subscriber declaration for the Heavy Goods Vehicle
transit toll”).
Identification of the vehicles for which you wish to order badges
An Excel file may be submitted instead of the table above, as long as all the columns are included.
Additional information about the details in the table:
Registration no.: See on the registration
certificate.
Country: country of registration.
Euro class: “V9” on the registration certificate
or vehicle description, or on the COC or CEMT.
Number of axles of the tractor:
the number of axles of the vehicle.
Total number of axles (tractor+trailer):
the number of axles of the vehicle with its trailer.
GVWR of the tractor: See on the registration
certificate.
AGVW of the tractor: See on the registration
certificate.
National type: “J1” on the registration certificate.
Relationship to the vehicle(s): Specify whether you are the owner, renter or sub-lessee. If you are
none of these, you are the user of the vehicle.
* more information in the website customer area at www.axxes.eu
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Please complete the full details of each vehicle in the table below:
Number of
axles of the
cab
Total
number
of axles
GVWR
(tractor)
AGVW
National
type
User
EURO
emissions
class
Sub-lesse
Country
Renter
Registration no.
Owner
Vehicle
Relationship to the
vehicle(s)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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ORDER FORM
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:
Signatory’s name:
Signatory’s job title:
Signature [which must be preceded
by the handwritten comment in French
“Lu et Approuvé” (read and approved)]:
Company stamp:
Your contact office
AXXES
LYON
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]
AXXES
SAINT-MICHEL-DE-MAURIENNE
Plateforme du Tunnel
73500 MODANE
FRANCE
AXXES
SAINT-MARTIN-DE-CRAU
La Lieutenante
+33 (0)4 26 29 75 70
+33 (0)4 79 20 26 93
[email protected]
13558 SAINT-MARTIN-DE-CRAU
FRANCE
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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 100 0614
+33 (0)4 26 29 75 60
+33 (0)4 90 47 88 12
[email protected]
www.axxes.eu
TAXE POIDS LOURDS
MANDAT POUR LA DECLARATION DU VEHICULE ET LE PAIEMENT DE LA TAXE
Personne morale:
Adresse :
Je, soussigné :
Agissant en qualité de
dûment habilité(e) aux fins des présentes
Donne par la présente, mandat à AXXES SAS située à Tour Oxygène, 10-12 bd Vivier Merle, 69393 LYON CEDEX 03 – France, agissant
en qualité de Société Habilité de Télépéage
Pour déclarer mon (mes) véhicule(s) à l’enregistrement pour mon compte et me désigner comme redevable enregistré ainsi que
pour acquitter la taxe due au titre de la taxe poids lourds en mon nom et pour mon compte.
J’atteste avoir fourni à AXXES SAS, des pièces justificatives valides afin de procéder à l’enregistrement de mon (mes) véhicule(s).
Ainsi je me porte garant de l’exactitude et de la véracité des dites pièces au regard de la réglementation applicable.
Je déclare ne pas être lié contractuellement auprès d’une société tierce pour les services cités ci-dessus, ou, le cas échéant, avoir
effectué toutes les opérations de résiliation pour tout autre contrat d’abonnement contracté pour ces services auprès d’une société
tierce.
Je souhaite recevoir les détails de liquidation et donne, par la présente, mandat à Axxès pour solliciter en mon nom et pour mon
compte les détails de liquidation.
Liste des véhicules concernés par le présent mandat
Genre
National
N°
immatriculation
Qualité du signataire
(ou de la société représentée par le signataire)
au regard du/des véhicule(s)
Pays d’immatriculation
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
N/D
-
Fait à Lyon, le
Faire précéder la signature de la mention « Bon pour mandat »,
et apposer le cachet de l’entreprise.
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Axxès SAS au capital de 7 500 000 € / N° de SIRET 482 930 385 00026 / APE 5221Z - Tour Oxygène – 10/12 Bd Vivier Merle – 69003 LYON
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.
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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
Mai 2014
Form to be returned with your bank account details to your sales office
www.axxes.eu
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]
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AXXES
SAINT-MICHEL-DE-MAURIENNE
AXXES
SAINT-MARTIN-DE CRAU
Plateforme du Tunnel
La Lieutenante
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
Mai 2014
AXXES LYON
www.axxes.eu
TAXPAYER SUBSCRIBER DECLARATION FOR THE
HEAVY GOODS VEHICLE TRANSIT TOLL GUIDE
Who is affected by the Heavy Goods Vehicle transit toll ?
This transit toll is payable jointly by the owner, renter, sub-lessee, driver or user of any road freight transport vehicle
registered in France or abroad whose gross vehicle weight rating, or authorised gross vehicle weight in the case of an
articulated truck, is greater than 3.5 tonnes.
When registering each vehicle subject to the tax, the customer names the registered taxpayer who will receive
payment notices and statements relating to the transit toll.
LIST OF DOCUMENTS REQUIRED TO DECLARE A TAXPAYER SUBSCRIBER
FOR THE HEAVY GOODS VEHICLE TRANSIT TOLL
Mandatory documents
❏ EORI or TVA proof of less than 3 months old
❏ Vehicle registration certificate
❏ Certificate Company Registration
❏ The SHT (authorised transit toll collection company)
mandate
Paper depending on the case
❏
❏
❏
❏
The signed certificate of incumbency
Evidence of rental or sub-leasing
signed by all the parties involed
Evidence of use signed by all the parties involed
Proxy signed by all the parties involved
Documents needed to identify the COMPANY wishing to declare its vehicles
EORI OR TVA PROOF
It has to be less than 3 months old.
It is essential to prove that the company is registered.
You can get it from your Chamber of Commerce.
CERTIFICATE COMPANY REGISTRATION
It has to be less than 3 months old.
It has to include the name of an individual as legal representative. If the certificate of incorporation gives the name of a legal entity,
the Certificate Company Registration of this legal entity is also required and so on until the name of an individual appears. It will
only be accepted if it includes the name of an individual. If this is not the case, a certificate of incumbency is required certifying
that the person listed is the legal representative of the taxpayer’s company.
You can get it from your Chamber of Commerce.
CERTIFICATE OF INCUMBENCY
To be used to prove the name of the taxpayer subscriber company’s legal representative either by himself, because his name does
not appear on the Certificate Company Registration, or by another member of the company.
CERTIFICATE OF INCUMBENCY template
Day month year
I, the undersigned (full name, job title), of the company (company name, head office, address, share capital), certify that (full name) is the legal
representative of the company (company name).
Signed in……. On…….
For all legal intents and purposes.
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Signature and stamp
of the declarer
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Documents needed to identify the VEHICLES wishing to declare
VEHICLE REGISTRATION CERTIFICATE - VRC
Essential for each vehicle.
Exemple of french vehicle registration certificate
CEMT CERTIFICATION OR COC
The EURO POLLUTION class is required. The VIN code (“E”) or registration
(“A”) must appear on the VEHICLE REGISTRATION CERTIFICATE.
You can get it from your dealer or manufacturer.
If this information is given in “V9” on the vehicle registration there is no need
to provide a CEMT CERTIFICATION.
Case of RENTING or SUB-LEASING
In the case of a rental of 3 months or more, the renter or sub-lessee is the
registered taxpayer.
If the taxable vehicle is covered by a leasing contract, the registered
taxpayer is the lessee (long-term renter).
In the case of a rental contract of less than 3 months, the registered
taxpayer is the rental company. In this case, the CERTIFICATE COMPANY
REGISTRATION of the rental company are also required.
RENTING or SUB-LEASING
This is ONLY needed if neither lessor appears on the REGISTRATION DOCUMENT
in “C1” and “C3”. Only the last rental contract needs to be proved.
The registration must be clearly indicated.
RENTAL or SUB-LEASING CONTRACT
If you do not have a rental contract, a declaration is acceptable.
It must be signed by the last rental company and the last renter
(the HGV taxpayer).
RENTAL or SUB-LEASING CONTRACT template
Day month year
I, the undersigned (name and address of the rental/sub-leasing company) certify that I lease the vehicles with registration numbers (…; …) to the
company (name and address of the renter/sub-lessee company) for a period of XX months.
Signed in……. On…….
For all legal intents and purposes.
Signature and stamp of the
rental/sub-leasing company
Signature and stamp of the
renter/sub-lessee company
PROOF OF USE
Only complete these details for vehicles you neither own nor rent (e.g. borrow, use with no financial contract).
In this case, you will need to provide evidence of your use. Only the last rental contract needs to be proved.
The registration must be clearly indicated.
PROOF OF USE template
Day month year
I, the undersigned (name and address), owner of the vehicles with registration numbers (…; …), certify that I make them available to the company
(name and address).
Signature and stamp
of the owner company
Signature and stamp
of the user company
Juillet 2014
Signed in……. On…….
For all legal intents and purposes.
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