Company Registration Number or NZBN*
Company Name*
Company Trading Name (If applicable)
Nature of Business* Select nature of businessAccommodation and Food ServicesAdministrative and Support ServicesAgriculture, Forestry and FishingArts and Recreation ServicesConstructionEducation and TrainingElectricity, Gas, Water and Waste ServicesFinancial and Insurance ServicesHealth Care and Social AssistanceInformation Media and TelecommunicationsManufacturingMiningProfessional, Scientific and Technical ServicesPublic Administration and SafetyRental, Hiring and Real Estate ServicesRetail TradeTransport, Postal and WarehousingWholesale TradeOther Services
Period of Trading in Years*
Number of Staff* Select number of staff1 - 55 - 1010 - 2020 - 5050+
Please add 3 credit references. Must include: Business name, Contact, Phone number and e-mail.
Credit Reference 1*
Credit Reference 2*
Credit Reference 3*
First Name*
Last Name*
Email*
Phone Number*
Position Held* Select positionAccountant / FinanceAccounts PayableAdministrationArchitect / DesignerCaretaker / Maintenance & RepairChefEngineerHealth & SafetyHuman ResourcesInformation Technology (IT)ManagerMarketingNurse/DoctorOperations ManagerOwner / DirectorProduction Manager / SupervisorProject ManagerProperty ManagerPurchasing / LogisticsPurchasing ManagerQuality Assurance / ControlReceptionSalesStorepersonWarehouse Manager
Office Phone Number
Additional authorised purchasing person (if needed)
Invoice Email Address*
Proof of Identity Verification*
Street*
Delivery Address
Delivery Contact Name*
Delivery Contact Phone*
Payment in full is due by the 20th of the month following invoice.
Customers failing to honour their obligations may, without notice, have their credit facility withdrawn, any negotiated price discounts revoked and may also incur interest and collection charges.
This application may be subjected to credit checks and information therein may be provided to and requested from referees and other third parties for credit approval or collection of monies owed.
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I understand that by submitting this form I have read and agree to these terms and conditions.
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