Apply for a Credit Account.

Please note, this application form is only for businesses with delivery addresses in New Zealand.

How would you like to apply? *

As an individual
As a business

Please select a Dealership *

Business Information

Company Name *

Registered Trading Name *

GST Number *

Nature of Business *

Number of Employees *

Company Registration Number *

Date Company Established *

Smart Loyalty / Smart Trade Number (if applicable)

Company Accountant *

Company Phone Number

Company Physical Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Company Postal Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Ownership

(please insert Owner (s) / Directors (s) / Partners Name (s) in full)

1st Director / Proprietor’s Full Name

Title *

Full Name *

First

Middle

Last

Date of Birth *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

2nd Director / Proprietor’s Full Name

Title

Full Name

First

Middle

Last

Date of Birth

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Account Contact Information

Title *

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Account Contact Email Address *

Alternative email address for Invoice and Statement

Account Phone Number *

Alternative Phone Number

Date of Birth *

Drivers Licence Number *

Drivers Licence Version *

Vehicle Registration Number *

Alternative Contact

(please enter an additional contact person)

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Credit Limited requested *

Terms and Conditions

I/We hereby apply to open a credit account with Ingham Group Services Limited (Ingham), and its subsidiaries.

I/We have read and fully understand Ingham’s Terms and Conditions of Trade and agree to abide by them. All electronic communications regarding the set up and use of a credit account are subject to the provisions of the Electronic Transactions Act 2002.

Please click here to view our Terms and Conditions.

Accept Terms and Conditions*

Accept Terms and Conditions*

Signature

Clear Signature

Authorised Signatory

Name Authorised Signatory *

Name Authorised Signatory

Position Held *

Position Authorised Signatory

Date of Application *

Date of Application

_____________________________________

For office use only

ID Verified
Checks Completed
Application Approved
Application Declined

A/C No

Code

Approved / Declined by

Authorised by

Credit Limit

Date

Apply for a Credit Account.

Business Information

Ownership

1st Director / Proprietor’s Full Name

2nd Director / Proprietor’s Full Name

Please provide Trading References

Account Contact Information

Alternative Contact

Terms and Conditions

For office use only