Applicant Trading Name * Registered Business Name * Type of Business * Limited Company Partnership Sole Trader Nature of Business Period Trading Under Current Owners * Contact Details Name * Street Address * Postal Address * Phone/s * Email * Website Directors/Owners Name*Date of Birth*Address*Delete Name * Date of Birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Address * Contact Person for Account Enquiries Accountant * Bank & Branch * Phone * Email * Trade/Credit References Three trade references are required. Please do not use any utility companies. Name *Town/City*Phone/s*Email* Name * Town/City * Phone/s * Email * Name Town/City Phone/s Email Name Town/City Phone/s Email Credit Details Maximum Amount of Credit Required * Is an Order Number Required? * Yes No Payment Payment Method * Direct Credit Visa / Mastercard (surcharge of 2.5% applicable) American Express (surcharge of 5.0% applicable) International Transfer Declaration I confirm that Conroy * I confirm that I am a duly authorised officer of the company and the information supplied in this form is true and accurate to the best of my knowledge and acknowledge that I/we have read and accept the Terms and Conditions of Credit. View Terms and Conditions of Credit(opens in a new window) Customer Information: In accordance with the Privacy Act 2020; I/We authorise the Company to obtain such personal information as they require in response to their enquiries from any source. This information will enable the Company to determine my/out credit worthiness and will be used as a guideline in setting credit limits and may be used for debt collection purposes. In addition, the Company may use this information to communicate promotional activities to me/us and to provide information about the Company's products and services as well as any lawful purpose related to the Company's business. I/We authorise the Company to furnish to any third party details of this application and any subsequent dealings that I/we may have with the Company for the purposes stated above. I/We understand that: I/We have the right to access and request correction of information held by the Company about me/us. That the supply of the information on this credit application is voluntary but that the Company requires the information to process the application and without it may not be able to do so. Name * Designation *
