Credit Application Form

Customer Details

Company Name *

Trading Name *if different from above

NZBN / Company Number *

Nature of Business

Email for Invoices /Statement *

Billing Address *

Street address *

Suburb *

City *

Postcode *

Shipping Address

Street address

Suburb

City

Postcode

if different from billing address

Contacts

Management *

Management Phone *

Management Email *

Accounts *

Accounts Phone *

Accounts Email *

Purchasing *

Purchasing Phone *

Purchasing Email *

Account Type Requested

Please select one *

Prepayment7 Day Account20th of Month Account

All accounts remain on a prepayment basis until approved in writing

Payment Type *

Direct DebitCredit CardBank Transfer

Trade References

Please provide atleast 2 trade references. Trade references should be for suppliers consistend in value to the amount of business likely to be conducted with the service provider. Please ensure that the referees have consented to providing a reference before listing them below.

Business *

Phone *

Business *

Phone *

Business

Phone

Terms of Trade

By submitting this application, the customer agrees that, if approved for credit, all goods and servies will be subject to the Service Provider's Master Service Agreement. *

Privacy Authorisation (Privacy Act 2020)

The Customer authorises the Service Provider to collect, use, store and disclose the personal and business information provided in this form for the purposes of assessing creditworthiness, openeing and managing the account, recovering debts, and compllying with legal obligations. This includes:

a. Making enquires with referees, credit reporting agencies, and other third parties;
b. Sharing necessary information with collection agencies if required;
c. Retaining this form and related information as long as required by law.

The Customer acknowledges the right to access and correct personal information held by the Service Provider, in accordance with the Privacy Act 2020
*

Completed by

Name *

Position *

Signature *

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