30 day credit account application form - The Australian Wine Research Institute

Company details

Legal entity name*

Trading name*

ABN/ACN*

Type of legal entity*

(If 'Other' is selected, please enter type of legal entity.)

Date commenced*

Business address*

Street Address Address Line 2 City / Town State Postcode Country

Name of parent company (if applicable)

ABN/ACN of parent company

Credit limit requested (if applicable)

Contact person to receive analytical reports

Contact name (analytical reports)*

First Last

Email (analytical reports)*

Telephone (analytical reports)*

Contact person to receive invoices

Use the same contact details as the person receiving reports*

Yes
No

Contact name (invoices)*

First Last

Email (invoices)

Telephone (invoices)

Send invoices to business address listed above*

Yes
No

Send invoices to

Street Address Address Line 2 City / Town State Postcode Country

Trade references (please provide a minimum of three trade references)

Business name (trade reference 1)*

Contact name (trade reference 1)*

First Last

Contact phone number (trade reference 1)*

Address (trade reference 1)*

Street Address Address Line 2 City / Town State Postcode Country

Business name (trade reference 2)*

Contact name (trade reference 2)*

First Last

Contact phone number (trade reference 2)*

Address (trade reference 2)*

Street Address Address Line 2 City / Town State Postcode Country

Business name (trade reference 3)*

Contact name (trade reference 3)*

First Last

Contact phone number (trade reference 3)*

Address (trade reference 3)*

Street Address Address Line 2 City / Town State Postcode Country

Authorised person

Name of authorised person*

First Last

Position title*

Email (authorised person)*

Enter Email Confirm Email

Other important information

The AWRI's standard terms and conditions for the provision of services form an integral part of this application for the provision of commercial credit.

Please pay particular attention to clauses 14 to 17 which detail your specific agreement to allow the AWRI to seek personal information regarding your credit history from credit reporting agencies and other credit providers. The penalty interest that may be applied, should you not adhere to the 30-day payment terms, is also specified.

By submitting this form you acknowledge that you have read, acknowledged and consented to the collection, use, storage or disclosure of your Personal Information by the AWRI in accordance with the AWRI’s Credit Information Management Policy, Privacy Policy) and the Privacy Act 1988.

*

I have read the Terms and Conditions and hereby acknowledge that the person submitting this form is an authorised representative of the company and has the authority to bind the company in this contractual agreement.

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