Credit Account Application

All information provided will be treated in strict confidence

Applicant Details

Registered Business Name *

Trading Name *

Owner's Name *

Sole Trader / Partnership

Proprietor(s) *

Dentist Name *

Account Manager

Order Authorizer

Delivery Address

First Name *

Last Name *

Company (Optional)

Street Address *

Apt / Suite (Optional)

Suburb *

State *

Postcode *

Email *

Phone

Billing address differs from delivery address

Business Details

Years Established *

Years Under Current Owners *

ABN *

State of Registration *

Additional Notes (Optional)

Business Activity *

Trade References

Ref 1 Company *

Contact Person

Phone *

Ref 2 Company

Contact Person

Phone

Ref 3 Company

Contact Person

Phone

Signature & Agreement

Applicant Signature *

Click to upload signature imagePNG, JPG — max 50 KB

Date *

Terms and Conditions

1. Pay all invoices within 30 days from invoice date unless otherwise agreed in writing.

2. DentaPlus Australia may change credit limits or withdraw credit facilities at any time.

3. Goods remain property of DentaPlus Australia until payment received in full.

4. Interest may be charged on overdue accounts at 2% per month.

5. In default, applicant pays all recovery costs including legal and collection fees.

6. All information provided is true and correct.

7. Information may be shared with credit reporting agencies for assessment purposes.

8. Governed by the laws of New South Wales, Australia.

I have read and agree to the Credit Terms and Conditions. *