Loyalty form Full Name (required) E-mail (required) Address (required) Address Age (required) Phone Number (required) Approximate kms. driven in a week:(required) Number of persons in the household: Number of cars in the household: Do you have any particular choice of gas brand: WcFPetroCanada ShellChevronEssoMobilCostco Do you hold any other loyalty card giving you gas discount: YesNo Your approximate monthly requirement of gas/diesel in a month liters: Your approximate household income (optional): Employment status: EmployedSelf-employedBusiness