Badge Heavy Goods Vehicle

Transcription

1 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 Microwave toll badge VIAXXÈS SAT Offer Satellite toll badge VIAXXÈS SAT Manager Offer Satellite toll badge Customer area Customer area Customer area French tolls Tolls in France, Spain, Portugal and Belgium Tolls in France, Spain, Portugal and Belgium Tolls in France, Spain, Portugal and Belgium Heavy goods vehicle transit toll Heavy goods vehicle transit toll Remote update and modification services + OPTIONAL Toll (data transfer) I subscribe to the Viaxxès offer* with or French tolls (all motorway operating companies) Tolls (interoperability France + Spain + Portugal + Belgique) EDI (GPS + TOLL DATA) Remote update and modification services Geolocation and fleet management Viaxxès SAT Manager + OPTIONAL Toll (data transfer) 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 I subscribe to the Viaxxès SAT Manager offer* with I add in paying option EDI service or Transmission of Toll data presentation 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

2 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 Mandatory Alienor (Gascony motorway) Mandatory ALIS (local discount) Mandatory ATMB (Mont-Blanc motorway and tunnel) Mandatory SAPN (Paris-Normandy motorways) SFTRF (Fréjus road tunnel) Mandatory SANEF (motorways of north-eastern France) AREA (Rhône-Alpes motorways) Mandatory APRR (Paris-Rhin-Rhône motorways) ESCOTA (Estérel and Côte d Azur motorways) Mandatory CCIH (Tancarville and Normandy bridges) Mandatory ASF (motorways of southern France) Mandatory ALIS (A28) RCOUR (A9) Mandatory Mandatory 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: J 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 2

3 Please complete the full details of each vehicle in the table below: Relationship to the vehicle(s) Vehicle Registration no. Country EURO emissions class Number of axles of the cab Total number of axles GVWR (tractor) AGVW National type Owner Renter Sub-lesse User

4 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. 78/7 of 6 January 978 (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 0/2 Bd Vivier Merle 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 LYON Tour Oxygène 0-2 boulevard Vivier Merle LYON CEDEX (0) (0) lyon@axxes.fr SAINT-MICHEL-DE-MAURIENNE Plateforme du Tunnel MODANE SAINT-MARTIN-DE-CRAU La Lieutenante +33 (0) (0) st-michel@axxes.fr 3558 SAINT-MARTIN-DE-CRAU +33 (0) (0) st-martin@axxes.fr 4 Axxès SAS au capital de de / N de SIRET / APE 522Z Headquarters: Tour Oxygène 0/2 Bd Vivier Merle LYON -France PR

5 Personne morale: Adresse : TAXE POIDS LOURDS MANDAT POUR LA DECLARATION DU VEHICULE ET LE PAIEMENT DE LA TAXE Je, soussigné : Agissant en qualité de dûment habilité(e) aux fins des présentes Donne par la présente, mandat à SAS située à Tour Oxygène, 0-2 bd Vivier Merle, 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 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 Pays d immatriculation Qualité du signataire (ou de la société représentée par le signataire) au regard du/des véhicule(s) Fait à Lyon, le Faire précéder la signature de la mention «Bon pour mandat», et apposer le cachet de l entreprise. 3 Axxès SAS au capital de / N de SIRET / APE 522Z - Tour Oxygène 0/2 Bd Vivier Merle LYON

6 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 Name: Address: Creditor Axxès Tour Oxygène bd Vivier Merle Lyon Cedex 03 - Postcode: City: Country: IBAN: BIC: Signed in: Payment: Recurrent 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: FR05ZZZ Mandatory documents to provide Bank account details stating the IBAN and BIC numbers. Form to be returned with your bank account details to your sales office Axxès SAS au capital de de / N de SIRET / APE 522Z Headquarters: Tour Oxygène 0/2 Bd Vivier Merle LYON -France Mai 204

7 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: PO box: Postcode: Town: Cedex: Country: Telephone: Mobile: Fax: address of the legal representative*: * all communications addressed to this address will have the same legal status as registered mail. Additional contact** (optional) Surname/first name: Job title: Address: PO box: Postcode: Town: Cedex: Country: Telephone: Mobile: Fax: address*: ** to add more contacts, go to the website customer area at Mandatory documents to provide o invoicing o delivery o fleet manager 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. 78/7 of 6 January 978 (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 0/2 Bd Vivier Merle 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 LYON Tour Oxygène 0-2 boulevard Vivier Merle LYON CEDEX (0) (0) lyon@axxes.fr SAINT-MICHEL-DE-MAURIENNE Plateforme du Tunnel MODANE +33 (0) (0) st-michel@axxes.fr Axxès SAS au capital de / N de SIRET / APE 522Z Headquarters: Tour Oxygène 0/2 Bd Vivier Merle LYON -France SAINT-MARTIN-DE CRAU La Lieutenante 3558 SAINT-MARTIN-DE-CRAU +33 (0) (0) st-martin@axxes.fr Mai 204

8 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. Signature and stamp For all legal intents and purposes. of the declarer

9 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 C 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. Signature and stamp of the Signature and stamp of the For all legal intents and purposes. rental/sub-leasing company 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). Signed in. On. Signature and stamp Signature and stamp For all legal intents and purposes. of the owner company of the user company Juillet 204 2