Forecourt Name*

Hereby gives full authorisation to RELIANCE SECURITY TECHNOLOGIES LTD to act on the company's/retailer's behalf when dealing with any incidents involving the taking of fuel from the company/retailer and failing to pay.

Authorisation to include:

• Apply for any relevant details from DVLA with regards to the Registered Keeper.
• Submit an Invoice on behalf of the company for the cost of the fuel taken.
• Pursue the debt by any means as required by RELIANCE SECURITY TECHNOLOGIES LTD to recover the debt.

Retailer/Manager Name*

Signature*

Terms and Conditions:
This Agreement is the complete agreement between the RETAILER and RELIANCE SECURITY TECHNOLOGIES LTD, Concerning the subject matter of this Agreement and replaces any prior oral or written communications between the parties. There are no conditions, understandings, agreements, representations, or warranties expressed or implied, that are not specified herein. This Agreement may only be modified by a written document executed by the parties here to. The parties have caused this Agreement to be duly executed. Signatures appear are signature authorized to execute this Agreement. Correspondence of any parties of this agreement is authorised.

Date Signed*