"Credit Application Form - Sirona"

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CREDIT APPLICATION FORM
PLEASE COMPLETE AND RETURN IN A TIMELY MANNER TO AVOID ANY DELAYS
Customer Details
Name of entity
Company Number:
Physical Address:
Postal Address:
Delivery Address (if different
to physical address):
Phone Number:
E-mail address:
Account contact person:
Name
E-mail address: (if different
to above)
Direct Dial
Credit References
Referee 1
Company/Organisation
Name:
Contact Name:
Phone Number:
Referee 2
Company/Organisation
Name:
Contact Name:
Phone Number:
Names and Addresses of
Name:
Owners/
Residential Address:
Partners/Directors
Phone Number:
Name:
Residential Address:
Phone Number:
Name:
Residential Address:
Phone Number:
Dated:
/
/
1.
By signing this document the customer agrees to be bound by the attached terms of trade.
2.
The customer authorises Sirona Animal Health Partners to contact the persons listed above as credit references and those persons may
release information regarding the customer’s credit history. Signed by the customer:
_________________________________
_________________________________
Customer’s authorised signatory
Name of authorised signatory
CREDIT APPLICATION FORM
PLEASE COMPLETE AND RETURN IN A TIMELY MANNER TO AVOID ANY DELAYS
Customer Details
Name of entity
Company Number:
Physical Address:
Postal Address:
Delivery Address (if different
to physical address):
Phone Number:
E-mail address:
Account contact person:
Name
E-mail address: (if different
to above)
Direct Dial
Credit References
Referee 1
Company/Organisation
Name:
Contact Name:
Phone Number:
Referee 2
Company/Organisation
Name:
Contact Name:
Phone Number:
Names and Addresses of
Name:
Owners/
Residential Address:
Partners/Directors
Phone Number:
Name:
Residential Address:
Phone Number:
Name:
Residential Address:
Phone Number:
Dated:
/
/
1.
By signing this document the customer agrees to be bound by the attached terms of trade.
2.
The customer authorises Sirona Animal Health Partners to contact the persons listed above as credit references and those persons may
release information regarding the customer’s credit history. Signed by the customer:
_________________________________
_________________________________
Customer’s authorised signatory
Name of authorised signatory
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