Application for 30 Day EOM Trading Account
Please complete electronically
Company Name:Click here to enter text.
Trading Name:Click here to enter text.
ABN:Click here to enter text.
Year Commenced: Click here to enter text.
Company Phone:Click here to enter text.
Company Fax:Click here to enter text.
Company Email:Click here to enter text.
Registered Address:Click here to enter text.
Primary Delivery Address:Click here to enter text.
Email Address for Invoices and Statements:Click here to enter text.
Accounts Payable Name:Click here to enter text.
Accounts Payable Email:Click here to enter text.
Accounts Payable Phone:Click here to enter text.
Accounts Payable Fax:Click here to enter text.
Purchasing Email:Click here to enter text.
Purchasing Phone:Click here to enter text.
Purchasing Fax:Click here to enter text.
Directors Details
- Directors Name:Click here to enter text.
Mobile:Click here to enter text.
Address:Click here to enter text.
Email:Click here to enter text.
- Directors Name: Click here to enter text.
Mobile:Click here to enter text.
Address:Click here to enter text.
Email:Click here to enter text.
Trade References (No Transport or Utilities):
# 1 Company Name Click here to enter text. AR Email Address Click here to enter text.
# 2 Company Name Click here to enter text. AR Email Address Click here to enter text.
# 3 Company Name Click here to enter text. AR Email Address Click here to enter text.
Freight Details:
Carrier Name: Click here to enter text.
Account Number: Click here to enter text.
Notes: Click here to enter text.
Declaration and Guarantee
I/we hereby warrant that information supplied in this application is true and correct. I/we agree to and have carefully read the "Terms and Conditions"
In consideration of Pacific Hoseflex Pty Ltd granting credit to the business so named in this application, I/we whose name appear below, agree to be individually responsible for the payment of all monies now or at any time due and remaining unpaid by the said business. This guarantee and my/our liability under it shall not be affected by Pacific Hoseflex Pty Ltd granting time or any other indulgence.
Director Name:Click here to enter text.
Director Signature______
Date:Click here to enter a date.
Director Name:Click here to enter text.
Director Signature______
Date:Click here to enter a date.
How did your hear about us?
Other:Click here to enter text.
Document Number : 002 | Version 2
Date: 26 June 2013