Customer Credit Application /

Legal Name of Entity *

_{Only Australian Legal Entities}

ABN/ACN *

Trading Name *

Full name of Trust if Applicant is a Trustee

Account Type *

Number of Active Chairs At Practice

Phone *

Mobile *

Email *

Billing Address

Address Line 1 *

Address Line 2 *

City *

State/Region/Province *

Postal / Zip Code *

Country *

Delivery Address

Delivery Address same as a billing address

Address Line 1 *

Address Line 2 *

City *

State/Region/Province *

Postal / Zip Code *

Country

Practitioner Information - Must be completed if restricted products will be purchased

Practitioner Name

AHPRA Registration Number

Details of Accounts Person/Team

Contact Person *

Phone *

Email *

Director / Owner Information

Director / Owner 1 - Full Name *

Address *

Phone *

Director / Owner 2 - Full Name

Address

Phone

Trade References

Company Name 1 *

Contact Name 1 *

Company Address 1 *

Company Phone 1 *

Company Email 1 *

Company Name 2 *

Contact Name 2 *

Company Address 2 *

Company Phone 2 *

Company Email 2 *

All invoices are to be paid before the last working day of the month following the invoice date.

All goods remain the property of Healthware Aus Pty Ltd until full payment has been received. *

Healthware Aus Pty Ltd may (in assessing my application for credit) obtain personal information and seek from a credit reporting agency or other credit provider information about my credit arrangement and I understand that this information may include my credit worthiness, credit history or credit capacity. *

Healthware Aus Pty Ltd shall be entitled to charge interest on overdue invoices. Interest will be charged from the date when payment becomes due to the date payment is received at a rate of 10% per annum *

I/We acknowledge that if the account is overdue, Healthware Aus Ltd at its discretion, reserves the right to refer the account to a Debt Collection Agency and/or solicitor for collection and I/We agree to be responsible for all collection costs and expenses incurred in collecting overdue accounts.*

Accounts more than 30 days past due or in excess of their credit limit will be placed in suspension until all overdue invoices are paid in full. Provision of goods and services will re-commence once all overdue invoices are paid and the suspension has been lifted.

Healthware Aus Pty Ltd reserves the right to refuse or withdraw the applicant(s) credit facilities at any time if the applicant is in breach of these terms and conditions.*

I have read and agree to the Privacy Policy.

I have read and agree to the Terms & Conditions.

I/We acknowledge that the information provided within this application has been read and understood by me/us, and I/we declare that all the supplied information is true and correct in every detail. *

Signature

By Signing in the below box you are consenting to the use of electronic signatures by Healthware Australia.

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Verification Code

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Customer Credit Application

Billing Address

Delivery Address

Practitioner Information - Must be completed if restricted products will be purchased

Details of Accounts Person/Team

Director / Owner Information

Trade References

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