30-DAY CREDIT APPLICATION FORM
Company Name:
*
Trading Name:
*
ABN/ACN:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address - For General Notices:
*
example@example.com
Billing Address (if different from above address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address - For Account Statements:
*
example@example.com
Email Address - For Invoices:
*
example@example.com
Email Address - For Annual Price Increases or Product Changes affecting Ordering
*
example@example.com
Accounts Payable - Contact Full Name:
*
Accounts Payable - Phone Number:
*
Please enter a valid phone number.
Accounts Payable - Contact Email Address:
*
example@example.com
Please specify the nature of business (select one):
*
Please Select
Public Hospital
Private Hospital
Distributor
Aged Care
Allied Health Professional
Accommodation Food Services
Admin Support Services
Beauty Therapist
Cardiology
Charity/Non Profit
Cosmetic Surgery
Day Surgery/Clinic
Defence
Dental Surgeon
Education
Emergency Services
General Practitioner / Medical Centre
Gynae Surgeon
Neuro Surgeon
Veterinary
Pathology Lab
Enter Primary Shipping Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the address receive pallet deliveries?
*
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number:
Do you have additional Shipping Addresses?
*
Yes
No
Enter second additional Shipping Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the second address receive pallet deliveries?
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number:
Do you have a third Shipping Address?
Yes
No
Enter third additional Shipping Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the third address receive pallet deliveries?
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number:
Do you have a fourth Shipping Address?
Yes
No
Enter fourth additional Shipping Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the fourth address receive pallet deliveries?
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number:
Do you have a fifth Shipping Address?
Yes
No
Enter fifth additional Shipping Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the fifth address receive pallet deliveries?
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number:
Do you have more Shipping Addresses?
Yes
No
Enter remaining Shipping Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can the address/s receive pallet deliveries?
Yes
No
If yes, please provide the pallet preference (CHEP/LOSCAM/STANDARD PLAIN PALLETS)
If CHEP or LOSCAM is preferred, please state the Account Number/s:
Is there a Forklift on site?
*
Yes
No
Does the location have a Height Restriction?
*
Yes
No
If yes, what is the Height Restriction?
What is the preferred Delivery Times at location?
*
Do Deliveries require to be booked in prior to delivery?
*
Yes
No
Would you like to be notified of Consignment Tracking updates?
*
Yes
No
If yes, please provide the Email Address for notifications:
example@example.com
Would you like to Subscribe to Product Updates from Haines Medical Australia?
*
Yes
No
If yes, please provide the Email Address for updates:
example@example.com
Account declaration (note: all boxes must be ticked for application to be processed):
*
I hereby accept the pre-paid terms of the credit account
I hereby accept the Terms of Trade
I hereby accept the Cancellation and Returns Policy Accepted
By submitting this application, I confirm that I am the duly authorised officer nominated by the business and I accept all Terms and Conditions. I warrant that the information provided to me in this application is true and correct.
*
Yes
Signature
*
Your Title and Full Name:
*
Your Position:
*
Your Email Address:
*
example@example.com
Your Phone Number:
*
Please enter a valid phone number.
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