Wm. C. JACKSON & CO.PTY.LTD.

169 VICTORIA PDE, COLLINGWOOD.  VIC. 3066

PHONE:  03) 9417 3131         FAX:   03) 9417 2764

eMAIL: info@wmcjackson.com.au

PRIVATE & CONFIDENTIAL

Wm. C. JACKSON & COMPANY PTY.LTD. IS REQUESTED TO PROVIDE CREDIT FACILITIES FOR  -

BUSINESS NAME: 

BUSINESS ADDRESS:                                                                                           STATE:                        POSTCODE:

TELEPHONE NUMBER:                                                                                         FAX NUMBER:

eMAIL ADDRESS:

DELIVERY ADDRESS:                                                                                            STATE:                        POSTCODE:

PLEASE  INDICATE  IF APPLICANT IS:

COMPANY:                               ACN:                                                                    ABN:

PARTNERSHIP:                         ABN:

SOLE TRADER:                         ABN:

OTHER (specify):

FULL NAME & ADDRESS OF DIRECTORS/PARTNERS OR PROPRIETOR:

                    NAME                                                         ADDRESS                                                                                       TELEPHONE

1)

2)

3)

TYPE OF BUSINESS:                                                                                               DATE OF COMMENCEMENT:

NAME OF BANK and BRANCH:

TRADE REFERENCES (MINIMUM OF 3):

                    NAME                                                                           TELEPHONE                                                                  FAX or   eMAIL

1)

2)

3)

WHAT IS YOUR ESTIMATED MONTHLY PURCHASE VALUE FOR THIS ACCOUNT?

I/WE acknowledge that Wm. C. JACKSON & COMPANY PTY.LTD. (Including SEWPARTS)., has informed me/us in accordance with S18E(8)(c) of the Privacy Act 1988, that certain items of personal information about me/us contained in this application and permitted to be kept on a credit information file might be disclosed to a Credit Reporting Agency, and give authority to obtain references from the referees named above, and information deemed necessary by the credit provider from a Credit Reporting Agency now, and at any time in the future.

I/WE AGREE TO ABIDE BY THE GENERAL TERMS & CONDITIONS OF SALE AS VIEWED ON THE WEBSITE: http://www.wmcjackson.com.au/

NAME & TITLE (PLEASE PRINT)                                                           SIGN & DATE: