All information provided will be treated in strict confidence

Credit_form

Address : Unit 5, 4A Bessemer Street,
Blacktown, NSW 2148, Australia.

Our Email : sales@dentaplus.com.au

Phone : (02) 8625 2332

APPLICATION TO OPEN CREDIT ACCOUNT :
All information provided will be treated in strict confidence:

APPLICANT DETAILS :

Registered Business Name:

Sole Trader’s or partnership name:

Trading Name:

Owner’s Name:

Dentist Name:

Account Manager Name:

Order Authorizer Name:

Name of Proprietor(s):

Delivery Address Postal Address (if different from delivery) :

Building:

St/Suite:

City:

State:

Postcode :

Contact Details :

Phone:

Mobile:

Fax :

Email :

Business Details :

How long has this business been established?

How long have the current proprietors owned the business?

Please identify the activity of your business: (tick)

Dentist

Dental Specialist (specify)

Laboratory Specialist (specify)

Other (specify)

Laboratory

Professional Registration Number:

ABN:

State of Registration

Trade References :

Please give the names and phone numbers of three suppliers for trade reference purposes:

Name :

Phone :

Name

Phone

Name

Phone

Date:

Need Help?

Call us: (02) 8625 2332

Need Help?

Call us: (02) 8625 2332