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prepaid-energy-card
PREPAID ENERGY CARD
All APPLICABLE SECTIONS MUST BE COMPLETED
Vanddis prepaid Energy Card
Applicant Information
First Name:
(Required)
Last Name:
(Required)
Company Name:
Address:
(Required)
I.D. Number:
(Required)
Telephone:
(Required)
Cell Phone:
Email:
(Required)
Card Information
This option grants authorization for card to be used to pay for all services offered at Vanddis Station
Debit Permitted:
(Required)
Yes
No
Number of cards desired:
1
2
3
4
5
6
7
8
9
10
Card Identification
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (2)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (3)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (4)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (5)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (6)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (7)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (8)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (9)
(Required)
Plate Number(s) or Driver Name(s)
Card Identification (10)
(Required)
Plate Number(s) or Driver Name(s)
Signature and Customer Agreement
Everything I have stated in this application is correct to the best of my knowledge. VANDDIS is given permission to verify the information stated on this application. This application is property of VANDDIS B.V.
I have read and agree to the Terms & Conditions and Additional Disclosures.
Signature of Applicant
(Required)
Hidden
Date
MM slash DD slash YYYY
Terms & Conditions
(Required)
I agree to the
terms & conditions.
(Required)
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Contact Form
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Support
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Phone
+599 9 724 1459
Super
Super: XCG 1.866/Ltr
Diesel
Diesel: XCG 1.593/Ltr
Gas
Gas Chiki: XCG 16.00
Prepaid
Apply for a Prepaid Card
Postpaid
Apply for a Postpaid Card
