Test Form Credit Application -

Account Holders Details
Full Name of Organisation or Individual:*
Trading Name (if different):
Address:*
Postcode*
Proof of Address (e.g., Utility Bill):*

Cancelof
Previous Address (if less than 3 years):
Postcode of Previous Address
Full Name:*
Position:*
Landline Number:
Mobile Number:*
E-mail Address:*

Names and Addresses of Directors / Owners / Partners
(1) Name
(1) Date of Birth

MonthDayYear
Date
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Name
(2) Date of Birth

MonthDayYear
Date
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(3) Name
(3) Date of Birth

MonthDayYear
Date
(3) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name and Addresses of Two Trade References
(1) Company Name
(1) Credit Limit
(1) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Phone Number
(1) Email
example@example.com
(2) Name
(2) Credit Limit
(2) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Phone Number
(2) Email
example@example.com

Payment

Payment of your Account may be Made by Cash, BACS, or Debit Card
Would you Like a Login for Our Website (To Access Invoices, Place Orders, View Products, etc.)?*

YesNo

Account Security
Do you Require our Invoices to Quote a Purchase Order Number or Reference?*

YesNo
If Yes, Please Specify the Required Information, (e.g., Site Reference, Job Number, Purchase Order Number.)
Signatory 1

First NameLast Name
Signatory 2

First NameLast Name
Signatory 3

First NameLast Name
Signatory 4

First NameLast Name
Signatory 5

First NameLast Name
Signatory 6

First NameLast Name
Signatory 7

First NameLast Name
Signatory 8

First NameLast Name
Please Select if Applicable and Our Accounts Department will Contact you.

I Require Additional Signatories

Agreement
By completing this Credit Account Application you are confirming the following:

1) you have the requisite authority to apply for credit and act on behalf of the Customer;
2) the information supplied in this Credit Account Application is true and accurate;
3) you have read and accept the applicable Conditions of Sale of Coomers Limited (in particular, the conditions relating to Credit Accounts) on behalf of the Customer;
4) you agree and accept that any Account provided by Coomers Limited, and any and all orders placed and contracts made with Coomers Limited are conditional on and subject to the Conditions of Sale of Coomers Limited, which can be viewed at www.coomers.co.uk/business-conditions-of-sale
5) you agree and acknowledge that Coomers Limited may make enquiries of credit reference agencies and other third parties who may record those enquiries to process your Credit Account Application, that Coomers Limited may also disclose information about the conduct of your Credit Account to credit reference agencies and other third parties and that the information obtained from or provided to credit reference agencies or other third parties may also be used by Coomers Limited when assessing further applications by the Customer for credit terms and for debt collection, tracing and fraud prevention purposes.
Agreement & Terms*

By checking this box, I am signing as an Authorised Signatory of the Customer
Date of Signature*

DayMonthYear
Date
Signed Above by*

First NameLast Name
Position*

Credit Guarantee
This is a legally binding guarantee; it should only be signed by a director / owner / partner / trustee of the organisation or a third party who is prepared to personally guarantee performance of the Customer’s obligations. Your signature confirms you have read and understood its nature and effect.

In consideration of Coomers Limited agreeing to supply goods and / or services and to grant a credit account to the Customer, I hereby unconditionally guarantee the due and punctual performance and discharge of all of the Customer’s obligations and, in particular, the due and punctual payment on demand of all sums now or subsequently payable to Coomers Limited by the Customer (whether under a Contract or otherwise), including any financial obligations arising from any increase in the Customer’s credit limit granted by Coomers Limited from time to time, and I agree to indemnify Coomers Limited, and keep it indemnified, against all losses it may incur through any failure by the Customer to perform or discharge such obligations. I acknowledge and accept that this guarantee and indemnity is a continuing guarantee and indemnity and shall remain in force until all the Customer’s obligations have been fully performed and discharged and, in particular, until all sums due and payable to the Coomers Limited have been paid (in cash or cleared funds) in full.
Agreement and Terms*

By checking this box, I am signing as a Guarantor
Date of Signature*

DayMonthYear
Date
Signed Above by*

First NameLast Name
Position*
Please verify that you are human*
Should be Empty: