Trade Registration Form

Image title

VETERINARY REGISTRATION FORM

Practice Details

Customer Name *

Trading Name *

Proprietor *

Veterinary Registration Number (if applicable)

Clinic Phone Number *

Mobile Number

Buyer's Name *

Buyer's Phone Number *

Buyer's Email Address *

Buyer's Fax Number

Accounts Payable Name *

Accounts Payable Phone Number *

Accounts Payable Email Address *

Accounts Payable Fax Number

ABN *

ACN

Are you a member of UVG (United Vets Group)? *

YesNo

Online Information

Website Address *

Facebook Page URL *

Operating Hours

Days of operation *

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Hours of operation *

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

Select all that apply *

MondayTuesdayWednesdayThursdayFridaySaturdaySundayOther

Other Working Hours

Is there a forklift on site? *

YesNo

Brands of Interest to your Clinic

Please select all that apply *

ZIWI PeakShy TigerBell & BoneONE (with everything!)The Paw Grocer NORM (Get Wild)

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 (PO Box not accepted) *

Suburb *

State *

Postcode *

Shipping Email (contact for delivery updates) *

Billing Address (if different from shipping address)

Suburb

State

Post Code

Other Details or Special Instructions

Please list special instructions below, including any delivery 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