Credit Application Form

Credit Application Form
Customer Details
Company Name*
Trading Name (if different)
ABN*
ACN
Address*

Street Address

Street Address Line 2

CityState

Postal Code
Postal Address (if different)

Street Address

Street Address Line 2

CityState

Postal Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Accounts*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Years in operation*
Estimated Monthly Limit (PAYMENT DUE 30 DAYS)
References

provide 3 and must have the same or above the credit limit requesting
Company Name*
Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Company Name*
Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Company Name*
Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Directors Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal Code
Phone Number*
Please enter a valid phone number.
Date of Birth*
Drivers Licence No.*
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
Drivers Licence No.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
Drivers Licence No.
TERMS & CONDITIONS: To the fullest extent legally possible, all dealings between Comiskey Mining Services Pty Ltd and the Customer relating to any goods and/or services are subject to the Terms and Conditions set out on the following pages hereof unless otherwise agreed in writing.
DECLARATION & AUTHORITY: I/we hereby: (1) warrant that I/we have read and understood the terms of this application including the Terms and Conditions, (2) warrant that all information in this application is true and correct, (3) agree to make all payment when due and payable, (4) authorise Comiskey Mining Services Pty Ltd to verify with any third parties the details I/we have provided, (5) authorise Comiskey Mining Services Pty Ltd to give a credit reporting agency information about my/our credit arrangements and any default in payments of me/us, (6) agree that should Comiskey Mining Services Pty Ltd be required to take legal action to recover any amounts payable by me/us, then all of its legal costs and expenses will be recoverable against me/us on a full indemnity basis, (7) agree that credit facilities may be withdrawn by Comiskey Mining Services Pty Ltd at any time without prior notice.
Form Completed By
Name*

First NameLast Name
Position*
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

Credit Application Form

Customer Details

References

Directors Details

Form Completed By