Applicants name and head office details NB You must complete the boxes marked in red for the form to work.
Name
Company
Address
Town/City
County/State
Country
Postal Code
Telephone
Fax
Email

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Address to which invoices/statements should be sent (if different from above)
Address
Town/City
County/State
Country
Postal Code

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If part of a group, name of holding company
Name

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Name of person to contact repayment of invoices
Name
Telephone

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Status of applicant

Partnership, Sole trader, Limited company, Corporation, Nationised industry

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How long in business
Years/months

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Private details of propietors/partners (if sole trader/partnership)
Name
Address
Town/City
County/State
Country
Postal Code

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Private details of propietors/partners (if sole trader/partnership)
Name
Address
Town/City
County/State
Country
Postal Code

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Bank Details
Name
Address
Town/City
County/State
Country
Postal Code

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1st trade reference
Name
Address
Town/City
County/State
Country
Postal Code

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2nd trade reference
Name
Address
Town/City
County/State
Country
Postal Code

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Do you act as principal, agent or both

Principal, Agent, Both,

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Name of person supplying information
Name
Position
Date

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Thank you for your information, we will contact you shortly.