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NEW ZEALAND
AUSTRALIA
Customer Forms
Order Form
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Returned Goods Request
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Application for Credit Account
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Medtronic Prescription Form
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Terms and Conditions
Application for Credit Account
Application Date
Name / Company
Trading As
Postal Address
Post Code
Delivery Address
Telephone
Mobile
Fax
Email
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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