NEW ACCOUNT APPLICATION FORM

NEW ACCOUNT APPLICATION FORM

All items with * are mandatory fields
Company/Hospital Legal / Trading Name (the “Customer“):
Organisation Name:*
Applicant's Status:*

CorporationPartnershipSole TraderGovernmentOther
If individual or partnership, you MUST attach copy of drivers licence(s).
DUNS Number (if available):
Company Number
ABN/ACN*
Telephone
Website
Company/Hospital Registered Address *
Street Address*
City*
State*
Post Code*
Country*
Delivery Address *
Street Address*
City*
State*
Post Code*
Country*
Billing Address *
Street Address*
City*
State*
Post Code*
Country*
Purchasing Contact Name and Position *
Purchasing Contact*

First NameLast Name
Position*
Email*
Telephone*
Accounts Payable Contact Name and Position *
Accounts Payable Contact*

First NameLast Name
Position*
Email*
Telephone*
Year of incorporation or date business started

DayMonthYear
If change of ownership, date of change

DayMonthYear
Trade References
Reference 1
Company Name
Contact Name
Phone
Reference 2
Company Name
Contact Name
Phone
Reference 3
Company Name
Contact Name
Phone
Note: Additional information may be required as part of the credit check process.
Credit Data
Proposed Credit Limit*
Payment Terms (if not standard 30 days)
The Customer hereby makes this application for credit to Nanosonics Limited (“the Creditor”).

The Customer represents and warrants to Nanosonics Limited (“the Creditor”) that this information is true and correct to the best of its knowledge. I/we acknowledge that the Creditor has informed us that certain information may be shared with credit providers. I/we acknowledge that I/we will provide additional information that may be requested by the Creditor as may be deemed necessary as part of the credit check process.

I/we the undersigned, accept the General Terms & Conditions of Sale of the Creditor which are provided with the sales quote. I acknowledge reading the Terms & Conditions of Sale. The terms may be varied with written notice. Credit is approved at the discretion of the Creditor and may be withdrawn at any time with written notice.

The Customer represents that, as of the date of this application, it is solvent, able to pay its debt as they come due and has not filed, nor is the subject of, any petition in bankruptcy or for any reorganisation under any federal or state bankruptcy law. Should the foregoing representation become false at any time during the course of a business relationship between the Customer and the Creditor or while the customer owes any amounts to creditor, the Customer agrees to immediately notify the Creditor of all facts surrounding such occurrence.
Note: This document must be signed and dated to enable processing.
Acceptance by authorised person / director / proprietor
Full Name*

First NameLast Name
Position*
Signature*

Clear
Date*

DayMonthYear
Should be Empty: