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SHELL CUSTOMER REGISTRATION FORM FOR SHELL E-BOXES
ECOTAX and French, Spanish, Portugal and Liefkenshoek tunnel e-Toll System To order your e-boxes for Shell InterRoute Plus, please :

1

- Complete this Customer Registration Form and the e-Boxes Order - Complete and scan the mandate - Scan (pdf format) the certificate of incorporation of the company - Scan (pdf format) the vehicle registration document of vehicles you want to order e-boxes For more information on documents to be collected to activate ITR+ e-box, please read the tab "Documents collection". Send it back via email :

2

Sign, date and add your company stamp to the Appendix and send it back to us :

If you need assistance, please contact us at the following number : or by e-mail:

Company Name (legal entity) VAT registration nr Type of customer Delivery address for e-boxes
1 address per euroShell Card Customer number

euroShell Customer nr
(8 digits)

or

EORI number

ZIP CODE COUNTRY (Use the drop down menu) Title of contact Person (Use the drop down menu) First Name (of contact person) Office Phone number (without country code and area code) e-mail address of the contact person Average monthly spend on French Motorway Tolls

CITY

Position (of contact person) Last Name (of contact person)

GBP

OR

EURO

This is my first order for InterRoute Plus e-toll box with Shell This is NOT my first order for InterRoute Plus e-toll box with Shell

Company Stamp : Date : Signature : 07/03/14

Signee Name :
By signing this document, you recognize that you read, understood and accepted the Appendix Shell InterRoute joined to the present document or consultable on our website www.euroshell.com. In order for us to send you the e-boxes, you'll need to return to the Shell address written on top of this document the Appendix signed and stamped.
Registered in England and Wales Company Registration. Number: 3625633 Registered office: Shell Centre, London, SE1 7NA

SHELL CUSTOMER REGI

ECOTAX and French, Spanish
Vehicle information

Contract information
Mandatory Mandatory Mandatory Mandatory Mandatory Optional

Mandatory

Mandatory

Mandatory

Mandatory

Nr of badges

Type of Equipement
Use the drop down menu.

Vehicle Country
Use the drop down menu. For further information, please refer below to the table named "Vehicle category"

Vehicle License Plate
As indicated on the vehicle certificate (with or without spaces and or dash)

Min Number of Axles Truck
Our advice is to indicate 2 by default. This data will be used for the set up of the badge.

Vehicle Min Number of Registration Date Axles Trailer (dd/MM/yyyy)

Vehicle Emission

EEV
Use the drop down menu

Gross Vehicle Weight Rating
Field F2 of the vehicle certificate or field F1 if F2 is blank

Authorized Gross Vehicle Weight
Field F3 of the vehicle certificate. If blank, please indicate the same weight than in field "Gross Vehicle Weight Rating"

Our advice is to Exact date on the vehicle Use the drop indicate 3 by default. certificate or leave it down menu This data will be used blank for the set up of the badge.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR ECOTAX + TISPL + ITR

BA BA BA BA BA BA BA BA BA BA BA BA BA

A78-J-751 T64-T-688 A05-T-735 403-J-478 O28-T-352 943-T-374 O28-T-353 E09-T-011 T42-M-638 J81-O-196 A03-K-884 M81-J-168 K67-E-004

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5 Euro 5

No No No No No No No No No No No Yes No

20100 18000 18000 18000 18000 19000 18000 18000 18000 18000 18000 18000 18000

20100 18000 18000 18000 18000 19000 18000 18000 18000 18000 18000 18000 18000

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62

63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101

102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179

180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200

CUSTOMER REGISTRATION FORM FOR SHELL E-BOXES

and French, Spanish, Portugal and Liefkenshoek tunnel e-Toll System

Delivery Address
Mandatory Mandatory Mandatory Optional : have to be filled if the badges have to be delivered to another address

Renting Compan

Optional (Mandatory if Owner of the vehicl

European Vehicle Category
Use the drop down menu. For further information, please refer below to the table named "Vehicle category"

Vehicle Type

Owner of the vehicle

Delivery Contact Title
Use the drop down menu

Delivery Contact LastName

Delivery Contact FirstName

Delivery Contact Street

Delivery Contact Addres Complement

Delivery Contact ZIP

Delivery Contact City

Delivery Contact Country
Use the drop down menu

Renting Company Name

Renting Company Steet

Use the drop down Use the drop menu : down menu : HGV = Truck LGV = Tis VL only C = You are the owner R = Vehicle is rented

N3 N3 N3 N3 N3 N3 N3 N3 N3 N3 N3 N3 N3

HGV HGV HGV HGV HGV HGV HGV HGV HGV HGV HGV HGV HGV

C C C C C C C C C C C C C

Renting Company information
Mandatory

Mandatory if Owner of the vehicle = 'R')

Zip Code Renting Company

City Renting Company

Country Renting Company
Use the drop down menu

VAT ID Renting Company

TISPL InterRoute TISVL ECOTAX + TISPL ECOTAX + TISPL + ITR

AL AD AT BA BE BG BY CH CY CZ DE DK EE ES FI FR GB GR HR HU IE IT LT

LU LV MD MK NL NO PL PT RO RS RU SE SI SK TR UA

TAXE POIDS LOURDS
MANDAT POUR LA DECLARATION DU VEHICULE ET LE PAIEMENT DE LA TAXE Entreprise (raison sociale, adresse) :

Je soussigné (NOM, Prénom) : Agissant en qualité de : 0 dument 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.
Qualité du signataire (ou de la société représentée par le signataire) au regard du (des) véhicule(s)

Liste des véhicules concernés par le présent mandat
Genre National
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Souslocataire

Propriétaire

N° IMMATRICULATION A78-J-751 T64-T-688 A05-T-735 403-J-478 O28-T-352 943-T-374 O28-T-353 E09-T-011 T42-M-638 J81-O-196 A03-K-884 M81-J-168 K67-E-004

ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND

#N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A

X X X X X X X X X X X X X

Fait à , le

07/03/14

Faire précéder la signature de la mention « Bon pour mandat », et apposer le cachet de l’entreprise                    

Locataire

PAYS D’IMMATRICULATION

Utilisateur

Axxès SAS au capital de 7.500.000,00 Euros Tour oxygène 10-12 Bd Vivier Merle 69393 LYON CEDEX 03 RCS Lyon 482 930 385 N° TVA : FR40482930385

For information only, do not fill in the English version

HEAVY GOOD VEHICLES TAX
MANDATE FOR THE REGISTRATION OF VEHICLES AND PAYMENT OF THE TAX Company name and address: I the undersigned [Last name, First name] : Acting as : duly authorized for the purpose of this mandate

Grants by this letter, mandate to AXXES SAS located Tour Oxygène, 10-12 bd Vivier Merle, 69393 LYON CEDEX 03 – France, acting as SHT (Société Habilité de Télépéage – Approved Electronic Toll Company) To declare my vehicle(s) for registration on my behalf and nominate me as the liable registered person as well as paying the tax applicable to the heavy good vehicles in my name and for my account. I hereby confirm that I have given to AXXES SAS, valid supporting documents in order to proceed registration of my vehicle(s). Thereby, I am answerable for the accuracy and veracity of the documents in light of the applicable regulation. I declare not being contractually bound to a third party supplier for the above described services, or, if required, having conducted all necessary actions for the termination of any other subscription contract taken for the above services to a third party supplier. I wish to receive the detail of tax assessments and give, by this letter, mandate to AXXES SAS, to obtain on my behalf and my account the assessment details.
Description of the signatory (or the company represented by the signatory) in view of the vehicles(s)

List of vehicle affected by the present mandate
National Gender Vehicle Registration Number (VRN)

Rentee

Owner

Done at …………………. on .… / …. / …….

Before the signature, please hand-write « Bon pour mandat », and stamp it with the stamp of your company

Axxès SAS au capital de 7.500.000,00 Euros Tour oxygène 10-12 Bd Vivier Merle 69393 LYON CEDEX 03 RCS Lyon 482 930 385 N° TVA : FR40482930385

User

Vehicle Registration Country

Sub rentee

des présentes

385

385

Object >> Redevable / beholden Redevable category (by default, for Ecomouv, the beholden Is the name on the vehicle registration certificate) Owner or Leased vehicle (for less than 3 months) Tenant of the vehicle (for more than 3 months) or Sub-tenant (for more than 3 months) User

Redevable / beholden

Certificate of incorporation

Mandate

Company

Mandatory

Mandatory

Additional information

AT proof, EORI proof, proof of company registration to the chamber of commerce or proof of association creation

Please find some recommendations to transfer documents :

- You remain responsible of documents until they come to Shell - Always use a encrypted format using WINZIP, before sending it to Shell - Whatever is the sending format (email, USB key, CDROM), send password separately from the winzip fi See below the process :

Sending a ZIP file with encryption
Store the file on a location. Go to the location and right click on the file. Chose the option – Send to -> Compressed (zipped) Folder

A Zip file will be created with the same name as the original file. Open the Zip file by double clicking:

Choose the option Encrypt in the menu icons:

Below screen will appear that allows you to enter a password (2x)

Please ensure the encryption type is set to 256-Bit AES encryption:

Click on OK

The file name will now show it is encrypted as the file has a * – Example.txt*

The Zip file can now be attached to an e-mail and send to the receiver.

Vehicle

Vehicle registration certificate

Certificate of conformity (COC)

CEMT authorization

- If no proof document for axle: number of axle will be considered as "4 and +" by Ecomouv. Mandatory - If no proof document for EURO class: Ecomouv' will use the most unfavourable Euro class.

Out of UE: At least one of this 3 documents must be provided with the Vehicle registration certificate.

ely from the winzip file

e

Manufacturer certificate

Leasing/rental contract

Outsourcing contract

f axle will be considered as "4 and +" ouv. Mandatory

mouv' will use the most unfavourable ss.

Mandatory

Mandatory if name of the Mandatory if name of the ts must be provided with the Vehicle company is not the one company is not the one rtificate. mentioned on Vehicle mentioned on Vehicle registration certificate. registration certificate.

Type of vehicle code
A L M1 M2 M3 N1 N2 N3 I

Other Motor vehicles with two or three-wheel and four motor Vehicles designed and constructed for carrying 9 passengers included the driver Vehicles designed and constructed for carrying more than 9 passengers included the driver and h Vehicles designed and constructed for carrying more than 9 passengers included the driver and h Vehicles designed and constructed for the transport of goods and having a maximum mass not e Vehicles designed and constructed for the transport of goods and having a maximum mass betwe Vehicles designed and constructed for the transport of goods and having a maximum mass excee Not known

Vehicle Country Code
ALBANIA ANDORRA AUSTRIA BÉLARUS BELGIUM BOSNIA BULGARIA CROATIA CYPRUS CZECH REPUBLIC DENMARK ESTONIA FINLAND FRANCE GERMANY GREECE HUNGARY IRELAND ITALY LATVIA LITUANIA LUXEMBURG MACÉDOINE MOLDOVIA NETHERLANDS NORWAY POLAND PORTUGAL ROMANIA RUSSIA SERBIA SLOVAKIA SLOVENIA SPAIN SWEDEN AL AD AT BY BE BA BG HR CY CZ DK EE FI FR DE GR HU IE IT LV LT LU MK MD NL NO PL PT RO RU RS SK SI ES SE

SWITZERLAND TURKEY UKRANIA UNITED KINGDOM

CH TR UA GB

Definition

Other Motor vehicles with two or three-wheel and four motor Vehicles designed and constructed for carrying 9 passengers included the driver Vehicles designed and constructed for carrying more than 9 passengers included the driver and having a maximum mass not e Vehicles designed and constructed for carrying more than 9 passengers included the driver and having a maximum mass exce Vehicles designed and constructed for the transport of goods and having a maximum mass not exceeding 3,5 tonnes. Vehicles designed and constructed for the transport of goods and having a maximum mass between 3,5 and 12 tonnes. Vehicles designed and constructed for the transport of goods and having a maximum mass exceeding 12 tonnes. Not known

Comments

Coach companies are not liable for Ecotax

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