embryo

412 King street

newtown 2042

nsw

61-2-9565 2595

(e) info@embryo.com.au

 

Credit Application

 

This is an application for a commercial credit account (Strictly Confidential)

 

APPLICANT

 

 

 

Company Name                              ABN/CAN                                              

 

 

Trading Name                                                                                        

 

Business Address                                                                                   

 

                                                                                                       

 

Postal Address                                                                                      

 

Delivery Address                                                                                        

 

                                                                                                       

 

Phone                                     Fax.                                                   

 

Email                                      Contact                                                  

 

Tick one        Sole Trader            Partnership               Company

 

 

 

Has the applicant or anyone associated with the applicant been involved with bankruptcy or management or control of a business which has been wound up, had receivers appointed or entered into a scheme for the benefit of the creditors?            YES                       NO       

 

 

 

 

 

BUSINESS HISTORY

 

The applicant will be liable to notify embryo immediately in writing of any change in the details contained in this application.

 

Date Business Commenced:

 

Bank Details:

Name of Bank

Branch:

 

TRADE REFERENCES

 

Trade Reference 1

Name

Address

 

Phone

 

Trade Reference 2

Name

Address

 

Phone

 

Trade Reference 3

Name

Address

 

Phone

 

  1. Estimated value of credit required per month.                                             
  2. I/We hereby apply for the opening of a commercial credit account and provide the above information in support thereof.
  3. I/We have received a copy of embryo’s terms and conditions of sale and confirm that these may be updated from time to time.
  4. I/We acknowledge that I/We have read and accept embryo’s terms and conditions of sale

 

I                                        certify that I am authorized to sign this

 

credit application form on behalf of                                                            

 

and that the information given is true and correct to the best of my knowledge.

 

 

Signature of Applicant                                         Date                                     

 

 

 

PRIVACY ACT 1988 (PLEASE READ THE FOLLOWING CAREFULLY)

 

embryo shall hereinafter be referred to as the CREDIT PROVIDER

 

The applicants hereby acknowledge that they have been informed by the credit provider that personal information about them may be disclosed to a credit reporting agency.

The applicants hereby acknowledge that they have been informed that personal information about them may be disclosed by the CREDIT PROVIDER to a credit reporting agency.

The applicants hereby agree that the CREDIT PROVIDER may contact any trade reference or other credit references at any time whether now or in the future for the purpose of assaying credit worthiness The applicants hereby agree to the credit PROVIDER receiving from any other credit provider or providing to any other credit provider any credit information by way of report record or otherwise relating to credit worthiness for the purpose of exchange of information, assaying credit worthiness and notification of default at any time whether now or in the future.

The applicants hereby agrees to the CREDIT PROVIDER obtaining from a credit reporting agency a credit record on the applicant for the purpose of assaying this credit application and the applicant further consents to the CREDIT PROVIDER obtaining such reports from time to time for the purpose of assaying credit worthiness during the continuance of credit provision.

The applicants hereby agrees to the CREDIT PROVIDER obtaining from a business that provides credit information a report or information relating to our/my commercial dealings and using such information for the purpose of assessor this application for credit.

The applicants hereby agrees that in the event of default of payment of my debts that the

Ph CREDIT PROVIDER may disclose ali information relating to my/our account to its collection agent for the purpose of receiving any or all amounts outstanding.