Customer Credit Application
Business Information
Company Name
*
Trading Name (if different from above)
*
Company Email Address
*
example@example.com
Telephone Contact Number
*
Company Type
*
Private Limited Company (LTD)
Public Limited Company (PLC)
Limited Liability Partnership (LLP)
Sole Trader
Partnership
Charity
Government Body
Other
Company Registration Number
VAT Registration Number
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Account/Contact Details
Accounts Contact Name
*
First Name
Last Name
Account Contact Email
*
example@example.com
Account Contact Position
*
Accounts Contact Telephone Number
*
Please enter a valid phone number.
Invoice Address (if Different)
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Anticipated Annual Spend
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Trade Reference 1
Company Name
*
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Telephone
*
Please enter a valid phone number.
Trade Reference 2
Company Name
*
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Telephone
*
Please enter a valid phone number.
Authorisation
Authorised Person Full Name
*
First Name
Last Name
Email
example@example.com
Authorised Person Contact Number
Please enter a valid phone number.
Authorised Person Email Address
example@example.com
Due to Data Protection Laws, we are unable to process your application without your permission to request Trade References. Completion of this form authorises Paradigm Pump Services to obtain credit references and approach these for information relevant to your account.
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Authorised Person Signature
The signature below demonstrates your acceptance of Paradigm's Terms and Conditions and all the information completed in this form is correct and accurate
Signature
*
Today's Date
-
Month
-
Day
Year
Date
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Submit Credit Application
Submit Credit Application
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