Customer Forms

Application for Credit Account

Application Date

Name / Company

Trading As

Postal Address

Post Code

Delivery Address

Telephone

Mobile

Fax

Accounts Payable Contact

Registered Office

Nature of Business

Names of Owners of Business

Company Accountant

Company Solicitor

Note: USL and EBOS DO NOT give Trading References Trading References

Please include Account Number where applicable

Reference 1

Name

Phone

Address

Account No

Reference 2

Name

Phone

Address

Account No

Reference 3

Name

Phone

Address

Account No

Spend

Monthly Credit Expectation
(GST Inclusive)

Customer Acknowledgements

I / We hereby apply for a credit account with InterMed Medical Ltd

I / We understand that under your conditions of trade, full payment is due on the 20th of the month following the date of the invoice.

I / We agree that all goods remain the property of InterMed Medical Ltd until full payment is received

I / We agree that InterMed Medical Ltd reserves the right to uplift unpaid goods at their discretion

I / We consent to InterMed Medical Ltd collecting any information that may be required to evaluate my / our credit worthiness

InterMed Medical Ltd's full terms of trade are on the back of all invoices.

Authorised Signatory Name

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