Chapman & Rivett

Customer Details
Trading Name:		Telephone:
Business Address:		Fax:
Post Code:
Postal Address:
Post Code:
Contact Names:		Purchasing:
Accounts Payable:
Website Address(es):		Email Address(es):
Customer Information
Registered Business Name No.		Not Applicable
If Company		Not Applicable
Name:		ABN:
		ACN:
Nominal Capital:		Paid Up Capital:
Registered Office Address:		Post Code:
Date of Incorporation:		State Where Incorporated:
If Trustee of Trust:
Name:		Date of Commencement:
Names of Related Companies:
Proprietors/Directors Details
Full Name(s) and Address(es) of Sole Traders, Partners, Directors:
Name:		Telephone:
Address:		Post Code:
Name:		Telephone:
Address:		Post Code:
Name:		Telephone:
Address:		Post Code:
Name:		Telephone:
Address:		Post Code:
Has Any Proprietor/Partner/Director been registered under any part of the Bankruptcy Act or any Special Financial Arrangement?
Give Details:		Not Applicable:
Business Information
Nature of Business:		Date Commencement:
Date When Current Proprietors commenced this Business:
Plumbers/Builders/Electricians Licence No. (s):
No. of Branches:		No. of Employees:
Premises:	Owned Leased	Name of Landlord
Special Delivery Instructions
Trade References
Company		Suburb
State		Average Monthly Value
Contact		Phone
		Fax
Company		Suburb
State		Average Monthly Value
Contact		Phone
		Fax
Company		Suburb
State		Average Monthly Value
Contact		Phone
		Fax
Financial Information
Expected Monthly Purchases:		Sales Exempt No:
Bank:		Branch:
Account No:
Application for credit
The Customer applies for, and the Guarantor(s) (if applicable), request(s) Chapman & Rivett (SA) to open a Credit Account in the name of the Customer and to supply Goods and/oe services to the Customer, and agrees to be bound by the Terms and Conditions of Sale appended hereto.
I declare that by authorising this form - it binds the applicants as a written signature.
Authorised Signature:
Date:
Authorised Signature to Terms and Conditions:
Print Signatory's Name:
And indicate if:
Sole Trader
Partner
Director
Or if
Emplyee
Position: