Wholesaler Retailer Application Form

Wholesaler Retailer Application Form

Application for Credit Account
Organisation Details
Trading Name of Organisation
New Zealand Business Number
Type of Business

Other (please specify)
Nature of Business
Full Legal Name of Organisation ("The Customer")
How long has the organisation been trading?
Delivery Address

Street Address

Street Address Line 2

City / TownRegion

Post Code
Postal Address

Street Address

Street Address Line 2

City / TownRegion

Post Code
Address of Registered Office (if different from physical address)

Street Address

Street Address Line 2

City / TownRegion

Post Code
Contact Details
Contact Person

First NameLast Name
Phone Number

e.g. 0210000000
Email Address
example@example.com
Accounts Email Address
example@example.com
Credit References

Please supply three (3) business's we can contact for a credit reference.
Business One
Company Name
Phone Number
Accounts Contact

First NameLast Name
Length of Trade
Business 2
Company Name
Phone Number
Accounts Contact

First NameLast Name
Length of Trade
Business 3
Company Name
Phone Number
Accounts Contact

First NameLast Name
Length of Trade
If you are unable to provide three (3) credit references, please supply the details of a guarantor.
Name

First NameLast Name
Phone Number
Address

Street Address

Street Address Line 2

City / Town Region

Post Code

Organisation Details