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Request For Credit Terms

Type of Organisation: (Please tick)

Sole Trader
Partnership
Company
Trust
Other

Legal Name (the BUYER):

Registered Office:

ABN Number:

Paid up Capital:

Trading or Business Name:

Delivery Address:

Postal Address:

Telephone:

Fax:

Mobile:

Email:

Personal Details of Sole Trader, Partners or Directors (If Proprietary Company)

1. Full Name:

Home Address:

Home Phone:

Mobile Phone:

Date of Birth:

Driver Licence No:

2. Full Name:

Home Address:

Home Phone:

Mobile Phone:

Date of Birth:

Driver Licence No:

Contact Person for Account Payments:

Preferred Statement Delivery Method :

Mailed
Fax
Email

Bank Account Name:

Bank Name, Branch and Account No:

Trade References: (excluding Liquor & Fuel Suppliers, Credit Cards, Landlord, Power & Phone)

1.

Phone:

Fax:

2.

Phone:

Fax:

3.

Phone:

Fax:

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