Agri-Linc Credit Account Application Form

Full Trading Name*

Full Invoice Address Inc Post Code*

Main Telephone No*

Main Fax No

Web Address

Full Delivery Address Inc Post Code

If different to the invoice address

Delivery Address Telephone No

How long has the company been trading?*

Organisation Type*

Limited Company

Limited Liability Partnership

Partnership

Sole Trader

Company Registration No

If applicable

Full Registered Office Address Inc Post Code

If applicable

Full Name - Partner/Director 1*

Date of Birth - Partner/Director 1*

Address and Post Code - Partner/Director 1*

Full Name - Partner/Director 2

Date of Birth - Partner/Director 2

Address and Post Code - Partner/Director 2

Full Name - Partner/Director 3

Date of Birth - Partner/Director 3

Full Address and Post Code - Partner/Director 3

Full Name - Partner/Director 4

Date of Birth - Partner/Director 4

Address and Post Code - Partner/Director 4

VAT Registration Number

If applicable

Bankers Name & Full Address inc Post Code*

Bank Sort Code*

Bank Account Number*

Other Business Type and/or Buying Group Name

Membership Number

Purchasing Contact Name*

Purchasing Contact Direct Line

Purchasing Contact Mobile

Purchasing Contact Email*

Accounts Contact Name*

Accounts Contact Direct Line

Accounts Contact Mobile

Accounts Contact Email*

Approximate value of monthly credit required?*

Trade Reference 1 Name*

Trade Reference 1 Full Address Inc Post Code*

Trade Reference 1 Contact

Trade Reference 1 Telephone Number*

Trade Reference 1 Email*

Trade Reference 1 Fax Number

Trade Reference 2 Full Address Inc Post Code*

Trade Reference 2 Contact

Trade Reference 2 Telephone Number*

Trade Reference 2 Email*

Trade Reference 2 Fax Number

I the undersigned are authorised to apply for the credit account and accept the terms and conditions for the supply of goods as set out. I confirm that the information supplied is correct to the best of my knowledge and understand that you will need to complete relevant checks before confirming any credit account.

Form completed by*

Position*

Date*

Send me a copy of my responses

Privacy Notice|Report Abuse