Register Legal Name Trading Name * Billing Address (in full) * Deivery Address (if different from above) Phone * Fax Mobile Number Email Address * Type of Business Gift Shop Souvenirs Jeweller Pharmacy Crystal/New Age Number of Years Trading If Limited Liability Company - Address of Registered Office Full Name 1 * Ownership - please enter Owner(s) / Director(s) Name(s) Date of Birth Address Full Name 2 * Ownership - please enter Owner(s) / Director(s) Name(s) Date of Birth Address Bank Details Accountant Reference 1 * Credit Reference (No Utilities, lawyer, accountants, credit card companies or banks) Phone Number Reference 2 * Credit Reference (No Utilities, lawyer, accountants, credit card companies or banks) Phone Number Reference 3 * Credit Reference (No Utilities, lawyer, accountants, credit card companies or banks) Phone Number Purchase Order Number Required? Yes No Please note a physical copy will be requested from you when purchasing in store. I / We certify that the above information is true and correct and that I am authorised to make this application for credit. In accordance with the Privacy Act (1993) I authorize any person or company to give information as may be required in response to credit inquiries. Yes No I / We have read and understand the THE TERMS & CONDITIONS OF TRADE of The Oceania Jade Co., Ltd. And agree to be bound by these conditions. Yes No Full Name * Position *