Kellys Distributors Registration Form (Only for SEQ and Northern NSW customers)

KELLYS DISTRIBUTORS

Registration Form (Only for SEQ and Northern NSW customers)
Date*

MonthDayYear
Date
Sales Rep
Customer Code ( For Office Use Only )
Pricing
Customer / Business Name*
Trading as*
ABN Australian Business Number*
Contact Name*
Mobile 61*
Email address*
example@example.com
Business/Delivery Address*
Billing Address (Type "same" if the same as the above)*
Delivery Instructions If Any
Opening Hours*
Payment Method Type*

Credit/ Debit CardEFT / PrepaidCustom Payment Plan - DIscuss with your Sales RepOther
Need your order immediately?
Please provide a short description of the order and the contact details of the person concerned.
PLEASE NOTE THAT NO SURCHARGE IS APPLICABLE TO MASTER CARDS, VISA CARDS AND/OR DEBIT CARDS

I hereby authorise Kelly's Distributors to collect my payment details for the completion of the required process.
I hereby authorize Kellys Distributors to obtain and utilize my personal information as required for the completion of the processes described in this form.
Signature*

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215 Jackson Road, Sunnybank Hills, QLD 4109 Tel: 07 7 33452688Fax: 073345 2599

Email: info@kellysdist.com.au www.kellysdistributors.com.au
A receipt will be emailed to you for each transaction processed. Please ensure that sufficient funds are available for all purchases to avoid unnecessary delays to deliveries and to ensure a smooth process. Thank you for your continued business.
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KELLYS DISTRIBUTORS