Remtron Customer Application Form

PRELIMINARY INFORMATION

Use this section to confirm your point of contact at Remtron
Which Remtron Office will you be dealing with?*

Albury Automation_NSWBraeside_VICHobart_TASKeswick_SATraralgon_VICUnsureAlbury Compressor_NSWTownsville - QLDBrisbane - QLDNewcastle - NSWOther
Who is your sales contact at Braeside?
Who is your sales contact at Albury Compressor?
Who is your sales contact at Albury Automation?
Who is your sales contact in Adelaide?
Who is your sales contact in Hobart?
Who is your sales contact in Traralgon?
Who is your sales contact in Brisbane?
Who is your sales contact in Townsville?
Who is your sales contact in Newcastle ?
Applicant Details
Trading Name*
Business trading name ie XYZ Electrical
ABN*
Australian Business Number - 11 Digits
Legal Structure*

Public_Company/Listed_Company/Govt._OrganisationPrivate_CompanyTrustPartnershipSole_TraderCo-Op
Company Name*
Is the trustee a company*

YesNo
Name of Trustee Company*
ie Example Company Pty Ltd
ACN of Trustee Company*
9 Digit Australian Customer Number
Name of Individual Trustee*

PrefixFirst NameLast Name
Date Of Birth*

DayMonthYear
Name of Trust*
ie The XYZ Trust
Name of Partnership*
ie. John Smith and Jane Doe Partnership
Name of Sole Trader*

PrefixFirst NameLast Name
In Business Since*
Year
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the business address the same as your delivery address?*

YesNo
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Website
ie. www.example.com.au
Business Email*
accounts@example.com.au
Accounts Payable Email*
accounts_payable@example.com.au
Accounts Payable Phone Number

Area CodePhone Number
Order Confirmation Email*
purchasing_officer@example.com.au
Email For Invoices
accounts@example.com.au
Email for Statements
accounts_payable@example.com.au
If your business has any other communication requirements concerning supplier accounts then please detail these requirements below.
Other Email
other@example.com.au
Other Phone Number

Area CodePhone Number
Public Company Contact person

To be completed by an employee with the authority to establish a new trading account.
Position of Contact Person within Applicant business*
Please select
Other Position*
Applicant Director Details

To be completed by a director of the Company
Name of Director*

First NameLast Name
Applicant Trustee Details

To be completed by an Individual Trustee or a Director of the Trustee Company
Name of Individual Trustee or Director of Trustee Company*

First NameLast Name
Applicant Partner Details

To be completed by one of the business Partners
Name of Individual Partner*

First NameLast Name
Partner Date Of Birth*

DayMonthYear
Applicant Proprietor Details

Please provide the Sole Proprietor details.
Sole Proprietor Name*

First NameLast Name
E-mail*
example@example.com.au
Business Phone

Area CodePhone Number
Mobile Phone*
10 digit mobile phone number
Referral*
How did you hear about us?
Credit Application
Do you have an existing credit account with Remtron?*

YesNo
Please indicate your requested Credit Limit below and accept our Terms and Conditions to finalise the form
Did you wish to have access to the Remtron Online store?(Free shipping on orders over $99 Some exceptions apply)*

YesNo
Purchasing Name*

First NameLast Name
Purchasing Email*
example@example.com
What items are you considering purchasing from Remtron?
ie lighting, switch gear, drives, network peripherals, etc
Requested Credit Limit*
Please change to desired limit, default limit is $5,000
Terms and Conditions of Sale
Protecting your privacy

Protecting your personal information is important to us. We are bound by the Australian Privacy Principles in the Privacy Act. We safeguard your privacy and the security of your personal information by taking steps to protect the information we hold about you, from loss, unauthorised access, use, modification or disclosure and against other misuse.

When personal information that we collect is no longer required, we destroy or delete it in a secure manner. For more information, ask for a copy of our complete privacy policy.

For further information about privacy you can call us on 613 9587 1233.
Form Submitted On

MonthDayYear
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Should be Empty:

PRELIMINARY INFORMATION

Applicant Details

Public Company Contact person

Applicant Director Details

Applicant Trustee Details

Applicant Partner Details

Applicant Proprietor Details

Credit Application

Terms and Conditions of Sale