New Account Information & COD Credit Card Authorisation

New Account Information
Business Name
ABN
Website

Accounts Contact
Name

First NameLast Name
Position
Email
example@example.com
Phone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address (if different to Above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any Additional Emails or Contacts / Notes

Credit Card Authorisation Form
Date

DayMonthYear
Date
Trading Name
Credit Card Type
Card Number
Expiry Date
CVC - 3 Digit Number on Back
I authorise NLA Logistics Pty Ltd to arrange payment of my account as per details above, by debiting my credit card account as specified
above.

Credit Card Details are stored under your business name on Square Payments System. They are then destroyed after processing. If you wish for them to be withdrawn please advise in writing.

I acknowledge that NLA Logistics Pty Ltd may terminate this request at any time by written or verbal notice and I must adopt an alternative method of payment.

A surcharge per transaction of 2.5% will apply

I have read and understand the GENERAL TERMS AND CONDITIONS (overleaf or attached) of NLA Logistics Pty Ltd which form part of and are intended to be read in conjunction with this Credit Card Authorisation Form and agree to be bound by these conditions
Cardholders Name

First NameLast Name
Cardholders Signature

Clear
Date

DayMonthYear
Date
Please verify that you are human*
Should be Empty: