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Participating Retail Site

Participating Retail Site



Please complete print and sign and send to our office.

Boss Ltd. PO Box 2010, Kenilworth, CV8 9WS

Compulsory fields are marked with an asterisk.

Site Name *
Fuel Brand *
Site Manager's Name *  
Site Postal Address *
Postcode *
Site telephone number *
Preferred contact telephone number *
Retailer/Manager mobile number
E-mail address (Retailer/Manager) *
Password (If registering online) *
Trading Name (if different from above)
Payee name (Name to be used on repayment cheque) *
Address for cheques to be sent (if different from above)
Postcode
Authorised signatory name (print name) *
Authorised signatory (usual signature) Please sign the printed out form
Date of signing
I agree to the terms of agreement