[Company Logo][Company Name]
- Ref. No.:
- [Reference Number]
- Date:
- [Date]
- Card Provider:
- [Oil Company / Bank Name]
- Customer / Account ID:
- [Account Number]
1. Card Holder
| Name | [Employee Name] |
|---|
| Employee ID / Driver ID | [Employee ID] |
|---|
| Designation | [Designation] |
|---|
| Department / Territory | [Department] |
|---|
| Reporting Manager | [Reporting Manager] |
|---|
| Mobile (for transaction alerts) | [Mobile Number] |
|---|
2. Card and Vehicle Details
| Card No. (last 4 digits) | Card Valid Till | Linked Vehicle Reg. No. | Vehicle Type | Fuel Type |
|---|
| XXXX [Last 4 Digits] | [MM/YYYY] | [Registration Number] | Car / Two-wheeler / Commercial | Petrol / Diesel / CNG |
3. Limits and Permitted Use
| Control | Approved |
|---|
| Monthly limit | ₹[Amount] |
| Per-transaction limit | ₹[Amount] |
| Daily transaction count | [Number] |
| Permitted products | Fuel only / Fuel and lubricants |
| Cash withdrawal | Not permitted |
4. Card Holder Undertaking
- I will use the card only to fuel the linked vehicle [Registration Number] for official travel.
- I will keep the card and PIN secure, and will never share the PIN or let anyone else use the card.
- I will record the odometer reading in the trip log at every fill.
- I will keep fuel receipts or e-receipts and submit the monthly trip log by [Day] of the following month.
- I will report loss of the card immediately to Admin so that it can be blocked.
- Any use for a non-linked vehicle or non-official purpose may be recovered from me as per company policy.
- I will return the card on exit, change of vehicle, or when asked.
5. Monthly Reconciliation (Admin use)
| Month | Card Spend (₹) | Km Driven | Average (km / litre) | Remarks | Checked By |
|---|
| [Month] | [Amount] | [Kilometres] | [Average] | [Remarks] | [Admin Name] |
| [Month] | [Amount] | [Kilometres] | [Average] | [Remarks] | [Admin Name] |
| [Month] | [Amount] | [Kilometres] | [Average] | [Remarks] | [Admin Name] |
I acknowledge receipt of the fuel card described above in a sealed envelope with the PIN, and agree to the limits and undertaking stated in this form.
Card Holder
[Employee Name]Date:
[Date]Issued by
[Admin Name]Administration
Date:
[Date]Approved by
[Reporting Manager]Date:
[Date]