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Credit Application Form

Products

 Click here to download the credit application form

Please complete the form below: Required Fields * I/We hereby make an application for credit facilities and for the opening of an account with yourself. In support of this application, the following particulars are supplied.

Required Fields *

CUSTOMER DETAILS  

Trading Name:   *(if different)
Customer Email:   *

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TRADE REFERENCES


Please furnish current credit reference only - a minimum of 3 is required.

Supplier Name:   * Contact:   *
Telephone:   * Average Monthly:   *
Supplier Name:   * Contact:   *
Telephone:   * Average Monthly:   *
Supplier Name: Contact:
Telephone: Average Monthly:
Supplier Name: Contact:
Telephone: Average Monthly:
Supplier Name: Contact:
Telephone: Average Monthly:



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DIRECTORS AND SHAREHOLDERS

Name:   * ID Number:   *
Position Held:   * % Shareholding:   *
Name: ID Number:
Position Held: % Shareholding:
Name: ID Number:
Position Held: % Shareholding:
Name: ID Number:
Position Held: % Shareholding:
Name: ID Number:
Position Held: % Shareholding:


Are directors/members/partners prepared to sign surety:  Yes No
Have any of the directors ever been declared insolvent?  Yes No
Have any cessions been passed over the Customer's debts?  Yes No
Has the Customer given security for a bank overdraft?  Yes No
If the answer to any of the above questions is YES, please fi ll in the relevant details.

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BANKING & ACCOUNTING OFFICER DETAILS

Branch Name: Branch:
Branch Code: Account Type:
Account Number: Accounting officer's Name:


Telephone:
Are audited financial statements for the past year available?:   Yes No

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ACCOUNT INFORMATION

Credit Required: Per Month Per Year
Payment Terms Requested:
Click here to download our Terms And Conditions for the Credit Application
I accept the above terms and conditions for the credit application
Please type the correct answer in the box below:
  Click here to download the credit application form

JHB - HEAD OFFICE

Tel:+27-10-001-9200
+27-11-392-7533
Fax:+27-11-392-7590

Address:
Waterfall Distribution Campus,
Bridal Veil Road,
Midrand, 1685
Postal:
PO Box 75600,
Gardenview, 2047
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