Haines Medical Australia

Company Name:

Trading Name:

ABN/ACN:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (00) 0000-0000.

Email Address - For General Notices:

example@example.com

Billing Address (if different from above address)

Street Address

Street Address Line 2

CityState / 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.Format: (00) 0000-0000.

Accounts Payable - Contact Email Address:

example@example.com

Please specify the nature of business (select one):

Enter Primary Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the address receive pallet deliveries?

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?

Enter second additional Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the second address receive pallet deliveries?

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?

Enter third additional Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the third address receive pallet deliveries?

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?

Enter fourth additional Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the fourth address receive pallet deliveries?

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?

Enter fifth additional Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the fifth address receive pallet deliveries?

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?

Enter remaining Shipping Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Can the address/s receive pallet deliveries?

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?

Does the location have a Height Restriction?

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?

Would you like to be notified of Consignment Tracking updates?

If yes, please provide the Email Address for notifications:

example@example.com

Would you like to Subscribe to Product Updates from Haines Medical Australia?

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):

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.

Signature

Your Title and Full Name:

Your Position:

Your Email Address:

example@example.com

Your Phone Number:

Please enter a valid phone number.Format: (00) 0000-0000.

30-DAY CREDIT APPLICATION FORM