Credit Application Form

To apply for credit please fill in the fields below

Fields marked * are required

Name of Business: *
Delivery Address: *
Postal Address:
Post Code:

Owner or Directors
Owner / Director 1. *
Owner / Director 2.
Owner / Director 3.

Contact Details
Phone Business: *		Phone Accounts:
Fax Business		Fax Accounts:
Email Business *		Email Accounts:
Cell Phone

Do you wish to use an order number	Yes No
Do you want your statements emailed to you	Yes No
Do you want your invoices emailed to you	Yes No
Order number and part required (If applicable)
DECLARATION I have read and understand the terms of trade stated here and agree to abide by them. I further agree that supplier retain full ownership of the goods supplied under this credit agreement until such time as the price of the goods, Including any and all of the goods supplied have been paid for. Payment of all goods and services is strictly 20th of the month following invoice. Under the terms of the privacy act 1993,I authorize any person or company to provide you with such information as you may require in response to your credit enquires. I also authorize you to furnish any third party. Details of this application and any subsequent dealings that I may have with you. I undertake to pay the account in full on or before the due date. In default of any such promt payment, I shall undertake to pay late payment interest at the rate of 2%per month on any outstanding. All unpaid accounts will incur collection and legal fees payable to the client. I understand that warranty claims do not cover labour or the loss of vehicle working time. If items are not suitable goods shall be freighted back to Lorryland at my expence.

I agree to the above declaration

Name *

Date *

Enter Verification Code *