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Customer Application Form
Who is completing this Application?
*:
First Name, Middle Name, Surname
Registrant Email
*:
Job Title
*:
Confirmation of Authority
*:
I hereby confirm that I have the legal authority to complete this application on behalf of the applicant and that by entering my name and job title, it shall be deemed to have the same legal effect and validity as a handwritten signature in accordance with New Zealand law.
Yes
No
Date of Authority
:
Application Agreement
*:
This online application form must be completed by all new customers who wish to purchase goods and services on credit terms. It collects all the necessary information required by Absorb to set up your account, or your company's account, if your application is approved.
If your application is approved and credit terms are granted, payment will be due on or before the 20th of the month following the invoice date, without exception. Late or missed payments will result in your account being switched to a cash sale status.
Your monthly credit limit will be established based on your requested amount. Any orders exceeding this limit will require approval from Absorb's management.
Information Required
When completing this form, you will need to provide both personal and/or company details.
Please confirm your understanding and agreement.
Yes
No
Are you applying as a Company, Sole Trader, Partnership, Individual or Trust
*:
Company
Sole Trader, Partnership, Individual or Trust
Company Information
Physical Address
:
Trading Name
:
Are Purchase Order's Required
*:
Yes
No
Phone Number
*:
Company, Trust, Partnership Credit Limit
*:
Requested limit
$1,000
$5,000
$10,000
$15,000
$20,000
> $25,000
Postal Address
:
Company Email
:
If your Company Email is different from the Registrant Email added above - please enter below:
Company Number
*:
NZBN Number
*:
Name of Accounts Payable Contact
*:
Phone Number of Accounts Payable Contact
*:
Email of Accounts Payable Contact
*:
Do you have a Privacy Officer?
*:
Yes
No
How did you hear about Absorb?
*:
tick all that apply
Google
Referral / Word of Mouth
Vehicle Signage
Website
Long-time Customer
Other
Privacy Officer Name, Phone, Mobile and Email
:
Soletrader / Individual Information
Sole Traders / Individual's Full Name
*:
Full Name please
Are Purchase Order's Required? (Sole Trader / Individual)
*:
Yes
No
Soletrader / Individual Credit Limit
*:
Requested limit
$500
$1,000
$1,500
$2,000
$2,500
$4,000
Date of Birth
*:
GST Number
*:
Sole Trader only
Copy of Driver Licence (both sides)
*:
Residential Address
:
Phone Number (Sole Trader / Individual)
*:
Email Address (Sole Trader / Individual)
*:
If your Trading Email Address is different from the Registrant Email added above - please enter below:
Proof of Address
*:
To complete the account opening process, we require proof of address. You can provide a PDF screenshot of any document that clearly shows it was sent to you within the last six months, and clearly identifies your name and address
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