Credit Application Form

Please fill out all form fields and read the Terms & Conditions and Privacy Policy below.

Terms & Conditions

Phone

This field is for validation purposes and should be left unchanged.

Date(Required)

Reference Number

Client's Trading Name(Required)

Client's Legal Name(Required)

Phone(Required)

Mobile(Required)

Email(Required)

Postal Address(Required)

Address Line 1 Address Line 2 City ZIP / Postal Code

Physical address same as postal address

Physical Address

Address Line 1 Address Line 2 City ZIP / Postal Code

Contact Details

Health & Safety(Required)

Name Email

Purchase Order Requests(Required)

Name Email

Email Address for Invoices(Required)

Where should we send invoices?

Email Address for Statements(Required)

Where should we send statements?

Commercial Clients(Required)

Sole Trader

Partnership

Company

Trust

Company Number

Date Established(Required)

Contact 1(Required)

Contact 1 Position(Required)

Contact 1 Phone(Required)

Contact 2

Contact 2 Position

Contact 2 Phone

Details of: Owner (If Sole Trader), Partners (If Partnership), Directors (If Company), Trustees (If a Trust)

Full Name(Required)

Home Address(Required)

(Driver Licence, Passport, Birth Certificate)

Date of Birth(Required)

Home Phone(Required)

Full Name

Home Address

(Driver Licence, Passport, Birth Certificate)

Date of Birth

Home Phone

Trade References:

Business Name(Required)

Address or Account Number(Required)

Phone(Required)

Email(Required)

Business Name(Required)

Address or Account Number(Required)

Phone(Required)

Email(Required)

Business Name(Required)

Address or Account Number(Required)

Phone(Required)

Email(Required)

You certify that all information supplied is true and accurate and that you are authorised to make this application for credit. You have read and understand the Terms and Conditions of Trade of Mighty Kiwi Commercial which form part of, and are to be read in conjunction with this Credit Application Form. You agree to be bound by the Terms and Conditions of Mighty Kiwi Commercial and authorise the use of your personal information as detailed in the Privacy Act 2020 clause.

Signed (Client)

Date(Required)

Full Name(Required)

Position(Required)

Date of Birth(Required)

Driver's License No(Required)

Signed (Witness)

Date(Required)

Full Name(Required)

Position(Required)

Date of Birth(Required)

Driver's License No(Required)

Signed (Contractor)

Name(Required)

Date(Required)