Create A New Wholesale Account
Create A New Wholesale Account
Date
Date
*
/
DD
/
MM
YYYY
Contact Person - First Name
*
Contact Person - Last Name
*
Trading/Company Name for this account
*
Delivery Address
*
Is this a rural delivery address?
*
Is this a rural delivery address?
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Postal Address
Phone
*
Must be between
9
and
11
characters.
Currently Entered:
0
characters.
Fax
Must be between
9
and
11
characters.
Currently Entered:
0
characters.
Mobile
Must be between
10
and
12
characters.
Currently Entered:
0
characters.
Email
*
Web Site
Terms and Conditions
All goods remain the property of Topline Distribution Ltd until all outstanding bills are paid in full. Payment due date is strictly on 20th of the month following delivery. By typing your full name below, you agree that this is your registered legal name and your signature.
Signature: I hereby agree to the terms and conditions
*
Account Payment Options
*
Account Payment Options
I will pay directly to your bank account
I will pay be cheque or bank cheque
I will pay by credit card on the 20th month
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