Account Form

Dentist Details:*

TitleFirst NameSurname

Email:*

example@example.com

GDC No.:*

or Dental Council of Ireland Registration Number

Legal Practice Name:*

Practice Address:*

Property Number and Street Name

Locality / Village / Hamlet (Optional)

Town / CityCounty (Optional)

PostcodeCountry

Name of Key Contact for Accounts/Billing:*

Dialing Code:*

Phone Number:*

Format: 0000 000 000.

Phone Number:*

Format: 00 000 0000.

Email:*

example@example.com

Business Type:*

Limited CompanySole TraderPartnership

Home Address(s) Over The Last 3 Years:*

* Please note that for partnership businesses, information for a minimum of two partners is required.

Full Name, and Home Address(s) Over The Last 3 Years (Shareholder 1):*

Date of Birth:*

Date of Birth (Shareholder 1):*

* Please note, the same document cannot be used for Proof of Address and Proof of ID.

Proof of Current Address:*

eg. utility bills (gas, water, electricity, landline), bank statements, council tax bills, or full driving licence.

Proof of ID:*

eg. valid passport, a valid UK or EU photo driving licence.

Proof of Current Address (Shareholder 1):*

eg. utility bills (gas, water, electricity, landline), bank statements, council tax bills, or full driving licence.

Proof of ID (Shareholder 1):*

eg. valid passport, a valid UK or EU photo driving licence.

Full Name, and Home Address(s) Over The Last 3 Years (Shareholder 2):*

Date of Birth (Shareholder 2):*

* Please note, the same document cannot be used for Proof of Address and Proof of ID.

Proof of Current Address (Shareholder 2):*

eg. utility bills (gas, water, electricity, landline), bank statements, council tax bills, or full driving licence.

Proof of ID (Shareholder 2):*

eg. valid passport, a valid UK or EU photo driving licence.

Add 3rd Shareholder?

YesNo

Full Name, and Home Address(s) Over The Last 3 Years (Shareholder 3):*

Date of Birth (Shareholder 3):*

* Please note, the same document cannot be used for Proof of Address and Proof of ID.

Proof of Current Address (Shareholder 3):*

eg. utility bills (gas, water, electricity, landline), bank statements, council tax bills, or full driving licence.

Proof of ID (Shareholder 3):*

eg. valid passport, a valid UK or EU photo driving licence.

Company Name / Reg. No.:*

Year Trading Commenced:

Would you like authorise a laboratory to order products from us on your behalf?

YesNo

Lab Name: *

Lab Contact Name: *

Lab Address:*

Lab Email:*

example@example.com

Would you like authorise a 2nd laboratory to order products from us on your behalf?

YesNo

2nd Lab Name: *

2nd Lab Contact Name: *

2nd Lab Address:*

2nd Lab Email:*

example@example.com

Would you like authorise a 3rd laboratory to order products from us on your behalf?

YesNo

3rd Lab Name: *

3rd Lab Contact Name: *

3rd Lab Address:*

3rd Lab Email:*

example@example.com

Would you like authorise a 4th laboratory to order products from us on your behalf?

YesNo

4th Lab Name: *

4th Lab Contact Name: *

4th Lab Address:*

4th Lab Email:*

example@example.com

Agreement
I wish to apply for Credit facilities with Dental Direct UK Ltd.

I have read and agree to comply with the terms and conditions of sales printed overleaf.

Note Paragraph 7.4.3 - Interest will be charged on overdue items at 5% above the bank base rate. This account is open on a 30 days net terms unless amended by another written agreement.

Declaration by Applicant Seeking Credit
- I am duly authorised by the applicant business to enter into this agreement on its behalf. We agree that payment of your invoices will be made strictly in accordance with the credit terms stated thereon. We recognise that if payment of your invoices are not made by the due date, it will result in the matter being referred to a credit management company for recovery of the invoice debt. If also, we agree to indemnify you against the costs you incur in referring the matter to the credit management company to pursue the debt including the companies's current applicable fees for writing to us, any commission payable by you to the credit management company, all reasonable incidental costs of recovering the debt and interest as applicable.

- We understand that as a part of your assessment of us for the granting of credit, you will send details of our application to the credit management company who will search databases to which it has access. It may also search a credit reference agency for information relating to us (and in the case of non-limited business, also relating to the proprietors The credit reference agency will record the fact of that search in the name of the credit management company.

- I authorise our bankers to provide an opinion as to our suitability for the requested account.

- I authorise Dental Direct UK Ltd to obtain a consumer credit report and/or conduct a credit check from one or more credit reporting agencies to evaluate my creditworthiness. Information obtained will be used solely to determine eligibility for opening and maintaining an account with Dental Direct UK Ltd. By signing below, I consent to this credit check and affirms that all information provided in the application is true and accurate.

Signed:*

Name:*

Please Print Full Name

Date:*

Please verify that you are human*