Account Application

Applicant’s full legal name*

Applicant type

If other, please state:

Trading as:

Postal address

Physical address

Email address*

Contact name & position

Phone number

Mobile number

Fax number

Date of birth - provide a copy of passport or motor vehicle licence

If a limited liability company

Address of registered office

Date of incorporation

Incorporation number

Ownership

Full details of Directors

Director 1 name

Director 1 address

Director 1 phone

Director 2 name

Director 2 address

Director 2 phone

Director 3 name

Director 3 address

Director 3 phone

Financial & professional advisors

Accountant name

Solicitor

Bank

Branch

Account number

Trade references

Company

Contact name

Phone number

Account open since

Company

Contact name

Phone

Account open since

Company

Contact name

Phone number

Account open since

General description of services to be provided

I warrant to Laser Electrical Wairarapa trading as Laser Electrical Wairarapa:

that the above information is to the best of my knowledge, information and belief true and correct; and
that I have carefully read and agree to be bound by the terms and conditions as printed overleaf; and
that I am duly authorised to make this credit account application on behalf of the applicant and of anyone duly authorised to enter into future contracts on behalf of the applicant.

I agree to the Terms of Trade .