_________________

card company

PER TELEFAX to:

00 800 / 88 26 83 62

To the attention of ASFiNAG Maut Service GmbH:

Change of Payment Means Form

Dear Sir/Madam,

Hereby, we request the change of means of payment of our Post-Pay GO-Boxes from _______________________ to euroShell Card.

(old account partner)

More vehicles affected are listed in the attached excel file.

I take notice of the fact that changes will be processed by ASFINAG in order of receipt. An exact date of the conversion cannot be guaranteed, although ASFINAG will take due care to process your request as soon as possible.

Thank you in advance!

Kind regards

company: _________________________________________

contact person: _________________________________________

street: _________________________________________

postal code / city: _________________________________________

country: _________________________________________

telephone/fax #: _________________________________________

e-mail address: _________________________________________

_____________________________ ______________________________

city, date company stamp, signature

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