Name of Applicant, Business Name or Government Body
Trading Name of Applicant, Business Name or Department Name (if applicable)
Please specify if you are a: Sole Trader, Partnership, Company (private or public), Trust, Government or Other (please specify)
If the applicant is a Trust, the full name of the Trust including as trustee for the trading entity
If a trust, the Appointor’s name, address and phone No.
Physical Address
Postal Address
Main Phone No.
Email Address
How many years has your entity been trading? 1-5 yrs5-10 yrs10+ yrs
Payment Terms sort: 7 days14 days30 days
Name (Accounts Payable)
Contact Phone Number
Email (for sending invoices to)
Email (for accounts enquiries)
Name (Purchasing)
Email (purchasing)
Name (Applicant)
Title
Contact Number
Email
I declare that all the above information provided is correct and that the applicant agrees to pay all invoices as and when they become due.
Authorised Signatory:
Name
Date
The Name, Title and Date fields must be completed, or the application will be rejected. You agree that by completing the Name, Title and Date fields, you are making the equivalence of signing the form and that you declare that the details above are accurate and correct
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