First name*

Last name*

Email address*

Phone:

Mobile Phone:

Fax number:

Company Name:

Company type:*please selectWeb searchPress advertRadio advertReferref by othersOther

If applicable, please insert your company registration number below.

Company Reg Num:

VAT Reg Num:

Please give principle trading address below.

Address:

City:

Post code:

Please give registered office address if different from above.

Address:

City:

Post code:

If your company has a web site please give URL below.

web address:

Please give a brief description of your companies business in the box below.

What is the estimated annual turnover of your company this year?

Estimated turnover?

What is the estimated amount of credit turnover?

Estimated credit turnover?

Please give Company Director names and addresses below.

Director (1)

Director (1) address

Director (2)

Director (2) address

Director (3)

Director (3) address

Director (4)

Director (4) address

Director (5)

Director (5) address

How many branches does your company operate?

branches

Do you hold a Consumer Credit License?

If yes please enter CCL number below.

CCL Number

Date issued

Categories covered:

A

B

C

D

E

F

Off premises trade

Do you offer on-site trading, mail order, telephone sales and on-line sales facilities?

On-site sales:

Mail Order:

Telephone Sales:

Internet Sales:

Please give details of any warranties you offer.

Warranty offered?

Warranty term (yrs)

Warranty type:

Please give Bankers details below.

Bank:

Address:

City:

Postcode:

Account name:

Account num:

Please give your Accountants details below.

Accountants:

Address:

City:

Postcode:

Please use the box below to provide further relevant information.