VIP Company Account application form

Company Name:(Required)

Trading Name:(Required)

ABN/ACN:(Required)

Industries you work in:

Mining

Rural

Trades

Other

Purchasing Department Contact Name:(Required)

Please provide the name of the best contact person who will be our day to day contact for order notifications, updates and enquiries.

First Last

Purchasing Department Contact Phone Number:(Required)

If you don't have a purchasing department please simply add your phone contact

Purchasing Department Contact Email:(Required)

If you don't have a purchasing department please simply add your email.

Will you require an official order number?(Required)

Do you have a preferred Freight Company?

Yes

What is the name of your Preferred Freight Company?

Freight Company Account Number (if known)

MAIN ORDER DELIVERY ADDRESS:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address(Required)

Same as Delivery Address Above

Different to Delivery Address Above

POSTAL ADDRESS(Required)

Street or PO Box Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MORE THAN ONE DELIVERY ADDRESS?(Required)

No. Just the one above

Yes. There are other delivery addresses

Not sure yet. Will confirm

Please advise if we need to have more than one delivery address in our system to ensure orders are sent to the right spot.

You chose "Yes" above. Please advise other location addresses(Required)

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