ACTIVE ELECTRICAL - Customer Credit Application Form

CUSTOMER CREDIT APPLICATION FORM

ABN 29 005 246 799 | ACN 071 595 741
Name Of Applicant*

First NameLast Name
Preferred Active Branch*
Name Of Business*
Trading Address*

Street Address

Street Address Line 2

CityState

Post Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Post Code
Name Of Bank*
Branch*
Trading Period With Bank*
Date Of App*

DayMonthYear
Date
Director/Principal Of Applicant*
Drivers Licence Number:*
Email*
Upload Licence (Front)*

Cancelof
Upload Licence (Back)*

Cancelof
Accounts Payable Contact*
Phone Number
Mobile Number*
Type Of Business:*
ABN*
ACN*
Estimated Value Of Business*
Applicants Requested Credit Limit*
CREDIT REFERENCES
Reference 1 - Name*
Company Name
Reference 1 - Phone*
Reference 1 - Email*
Reference 2 - Name*
Company Name
Reference 2 - Phone*
Reference 2 - Email*
Reference 3 - Name*
Company Name
Reference 3 - Phone
Reference 3 - Email
I/We warrant that matters set out in this application form are true & correct in every detail and acknowledge that ActiveElectrical Distributors Pty Ltd will rely upon the information to provide credit to the Applicant. All goods supplied on credit must be paid for in full within 30 days of the end of the month in which the goods are supplied, unless otherwise agreed (in writing) at the time of sale. I/We hereby accept all of Active Electrical Distributors Pty Ltd terms and conditions of sale which are contained in theannexed document.
AUTHORISATION
Name:*
Position:*
Date*

DayMonthYear
Signature*

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By providing your authorisation signature above, you agree to the Active Electrical Distributors Terms and Conditions of Sale.
GUARANTEE & INDEMITY
In consideration of Active Electrical Distributors Pty Ltd (A.C.N 071 695 741) its successors and assigns ('the Company"), and any of its "related entities" as that term is defined in the Corporations Act 2001 agreeing to provide goods and/or services to the following Customer:
Name Of Sole Trader / Company*
Name Of Guarantor*
Residential Address Of Guarantor*
By providing your signature below, you agree to the Active Electrical Distributors Terms and Conditions of GUARANTEE & INDEMITY
AND THE GUARANTOR(S) HEREBY DECLARE that I/WE understand the nature and effect of the Guarantee & Indemnity and that I/WE have had the opportunity of obtaining legal advice before signing this Guarantee & Indemnity.
Guarantor Name:*

First NameLast Name
Guarantor Residential Address:*

Street Address

Street Address Line 2

CityState

Post Code
Guarantor Signature*

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Guarantor 2 Name (optional):

First NameLast Name
Guarantor 2 Residential Address:*

Street Address

Street Address Line 2

CityState

Post Code
Guarantor 2 Signature

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Witness Name:*

First NameLast Name
Witness Residential Address:*

Street Address

Street Address Line 2

CityState

Post Code
Witness Signature*

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Should be Empty:

CUSTOMER CREDIT APPLICATION FORM

CREDIT REFERENCES

AUTHORISATION

GUARANTEE & INDEMITY