This form is to apply for Credit with Belgian Beers Australia (Clemgary Providence Pty Ltd – ABN 55 636 574 180 – Liquor License 61621462920) Business DetailsThe Applicant(s) Business/Trading Name: Registered Company Name (if applicable): ABN: Liquor License Number: Telephone:Mobile (for deliveries):Email (for general enquiries): Email (for electronic invoices): Billing Address: Suburb/City State Postcode Corporate Structure: Company (Pty Ltd) Company Public Partnership Sole Trader Trustee Financial Details:Bank: Branch Terms: 14 days from invoice Other (negotiated) days from invoice Trade/Business references:Company/Supplier Name TelephoneCompany/Supplier Name TelephoneCompany/Supplier Name Telephone Proprietor/Owners:Name Date of Birth MM slash DD slash YYYY Address Driver’s License No: Name Date of Birth MM slash DD slash YYYY Address Driver’s License No: Name Date of Birth MM slash DD slash YYYY Address Driver’s License No: Agreement/Signature: All invoices are to be paid according to the terms of this Credit Application Any claims arising from invoices must be made within seven (7) working days of receipt of invoice By submitting this application, you authorise Belgian Beers Australia (Clemgary Providence Pty Ltd) to make inquiries into the banking/trade references provided. I agree to the above terms of this credit application Full Name Title Position Date MM slash DD slash YYYY
