Ostralos Account Application Form

Ostralos Account Application Form
Business Contact Information
Practice Name*
Company Name*
Dentist Name

First NameLast Name
Main Contact Name*

First NameLast Name
Phone*
Reception Email*
example@example.com
Accounts Email*
example@example.com
Accounts Contact Person

First NameLast Name
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal Address - only required if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BUSINESS / TRADE REFERENCES

Please provide two references
1. Company Name*
Phone Number*

Area CodePhone Number
2. Company Name*
Phone Number*

Area CodePhone Number
AGREEMENT

I/we irrevocably authorize Ostralos Ltd. to obtain credit references about my/our creditworthiness. I/we agree that credit is granted for payment by 20th of the month following the invoice date, and that until full payment is made to Ostralos Ltd., any goods supplied remain the property of Ostralos Ltd.
General terms and conditions of sale and supply are available on Ostralos.com
Please sign this document in full.

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