Credit Application Form

To be completed by Applicants – please complete all sections and read the Terms and Conditions of Trade overleaf

Date(Required)

REF No

CLIENTS TRADE NAME

CLIENT FULL or LEGAL NAME(Required)

Phone

Fax

Mobile

Email(Required)

Billing Address(Required)

Postcode(Required)

Physical Address

Postcode

COMERCIAL CLIENTS ONLY

ABN/ACN Number

Requested Credit Limit

Date Established

Contact 1

Phone

Position

Contact 2

Phone

Position

DETAILS OF OWNER (if Sole Trader) PARTNERS (If Partnership) OR DIRECTORS (If Company)

Full Name

Home Phone

Home Address

Full Name

Home Phone

Home Address

TRADE REFERENCES

Business Name 1

Address or A/C No

Phone

Fax

Business Name 2

Address or A/C No

Phone

Fax

I certify that the above information is true and correct and that I am authorised to make this application for credit. I have read and understand the TERMS AND CONDITIONS OF TRADE (overleaf or attached) of A & L Concrete Pumping Pty Ltd T/A Citywest Concrete Pumping which form part of and are intended to be read in conjunction with this Credit Account Application and agree to be bound by these conditions. I authorise the use of my personal information as detailed in the Privacy Act clause therein. I agree that if I am a Director/Shareholder (owning at least 15% of the shares) of the Client I shall be personally liable for the performance of the Client’s obligations under this contract.

SIGNED (CLIENT)(Required)

Name(Required)

Position

DOB