Selectrix Industries Pty Ltd - Account Application

ACCOUNT APPLICATION

ACCOUNT APPLICATION

PRIVATE AND CONFIDENTIAL

BUSINESS DETAILS

Name of Company *
Trading Name *
A.C.N No.
A.B.N No.

Trading Address *
Accounts Address
Postcode
PH No. *	Fax No.

Registered Office Address *
Postcode
PH No. *	Fax No.
Email Address Purchasing
Email Address Accounts
Please circle your main industrial function *
Estimated Purchases	$ Per Month

DELIVERY ADDRESS

Delivery Address 1 *
Contact
Postcode
PH No. *	Fax No.
Delivery Address 2
Postcode
PH No.	Fax No.

DIRECTORS

Surname	Given Names	Private Address	Owned or Rented	Telephone

TRADE REFERENCES

Trade Reference Name	Address of Reference	Telephone

HOW DID YOU HEAR ABOUT SELECTRIX?

PLEASE INDICATE HOW YOU CAME TO HEAR OF OUR COMPANY (Circle the appropriate)
Existing Customer	Yellow Pages	Internet
Advertisements	Other :
Sales Representative Name :

The Applicant

Warrants that the information in this application is correct.
Agrees that any change which affects the trading address, legal entity, structure of management or control of the applicant will notify Selectrix Industries Pty Ltd in writing on or immediately after the change becomes effective.
I/We acknowledge receipt of and agree(s) to observe the Company’s Terms and Conditions of Sale.

* I/We the undersigned, hereby authorize SELECTRIX INDUSTRIES PTY LTD to obtain trade references on me/us/our company, which are for the sole purpose of confirming trade referees and credit rating details supplied to Selectrix industries Pty Ltd via their ‘Account Application’ Form. TO COMPLY WITH THE PRIVACY AMENDMENT ACT I/We, the undersigned acknowledge(s) that Selectrix Industries Pty Ltd has informed me/us that certain items of personal information about me/us contained in the ‘Account Application’ Form lodged with their company and permitted to be kept on a Credit information file, might be disclosed to a credit Reporting Agency. Furthermore, I/We agree(s), in accordance with sections of the said Act, that use by Selectrix Industries Pty Ltd of the relevant information referred to in same, may occur for the purpose of assessment of our Account Application.

PLEASE RETURN THIS FORM TO SELECTRIX INDUSTRIES AT THE ABOVE ADDRESS

Signature of an Authorized Person

Full Name *	Title :
Email *

Security code
Input security code *