Credit Application Form

Date of Application*

Type of business

Name of Company/ Business

Company No.*

Postal Address*

Delivery Address*

Phone*

Mobile

Email (Main point of contact)*

Length of Time in Business

Desired Credit Limit Amount*

Bank and Branch

Purchasing Officer

Purchasing Email Address

Accounts Payable Officer

Accounts Email Address

Director #1 Individual Name*

Director #1 DOB*

Director #1 Home Phone*

Director #1 Residential Address*

Director #2 Individual Name (Optional)

Director #2 DOB (Optional)

Director #2 Home Phone (Optional)

Director #2 Residential Address (Optional)

Website account details

Username:*

(Must not contain spaces and must be less than 20 characters long)

Password:*

Confirm Password:*

We require three trade credit references and their contact phone numbers

Credit Reference #1*

Phone #1*

Credit Reference #2*

Phone #2*

Credit Reference #3*

Phone #3*

I submit the above details of my application for a credit account with your company and agree to the following conditions:

1.*

I acknowledge and accept the Galpro Stylex Terms & Conditions

2.*

Payment to be made 20th of the following month

3*

I hereby warrant my full authority to submit this account request and I accept responsibility in respect of any indebtedness arising in any way consequent hereupon

Name and Position*

Date*

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Credit Application Form

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