WHOLESALE TRADE REGISTRATION FORM

Business Details

Customer Name *

Trading Name *

Proprietor *

Store Phone Number *

Mobile Number

Buyer's Name *

Buyer's Phone Number *

Buyers Email Address *

Buyer's Fax Number

Accounts Payable Name *

Accounts Payable Phone Number *

Accounts Payable Email Address *

Accounts Payable Fax Number

ABN *

ACN

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Type of Business *

Specialty Pet StoreOnline Only Pet Specialty StoreGroceryGroomerOther (please specify)

Other

Online Information

Website Address

Facebook Page URL

Operating Hours

Days of operation *

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Hours of operation *

Which day/s are suitable for a store/office visit from one of our Sales Representatives

Please select all that apply *

MondayTuesdayWednesdayThursdayFridaySaturdaySundayOther

Other Working Hours

Is there a forklift on site? *

YesNo

Brands of Interest

Please select all brands that apply *

ZIWI PeakBell & BoneONE (with everything!)NORM (Get Wild)The Paw GrocerShy Tiger

Puppy School Program

Are you interested in our Puppy School Program and receiving complimentary puppy school packs? *

YesNo

Contact Details

Contact Name *

Job Title

Contact Email *

Contact Phone Number *

Address Details

Shipping Address *

Suburb *

State *

Postcode *

Shipping Email (contact for shipping updates) *

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Billing Address (if different from shipping address)

Suburb

State

Post Code

Other Details or Special Instructions

Please list special instructions below, including any shipping instructions

Indication of Preferred Payment

I wish to pay my account by *

Credit CardEFT (Electronic Funds Transfer)Cheque

Would you like us to send you a payment authorisation form to hold your details on file? *

YesNo

SIGNATURE

Signature *

Draw signature|Type signatureClear

Name *

Position *

Date *

Please Note:

This is not an application for Credit terms.

We normally require three full months trading history before we consider credit terms.

Please contact us should you wish to apply for a credit account.

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Number 1 (Australia) Pty Ltd

ABN 291 616 329 71

E: accounts@number-1.com.au  |  T: 02 8011 0205  |  F: 02 8076 3001