Credit Account Application Form

Please complete the form and submit online. You can type in your name in the Signature boxes below:


Date *
Date
Billing Address
Billing Address
Physical Address *
Physical Address
Date Established *
Date Established
Contact 1 *
Contact 1
Contact 2
Contact 2
Details of Owner (If Sole Trader), Partners (If Partnership), Directors (If Company) or Trustee (If a Trust)
Full Name *
Full Name
Home Address *
Home Address
Date Of Birth *
Date Of Birth
Full Name
Full Name
Home Address
Home Address
Date Of Birth
Date Of Birth
Trade References
Certification *
I certify that the information supplied in this form is true and correct and that I am authorised to make this application for credit. I have read and understand the Terms And Conditions of Trade of Gordon Adams Pipe Sales Pty Ltd which form part of, and are intended to be read in conjunction with this Credit Account Application and agree to be bound by these conditions. I authorise the use of my personal information as details in the Privacy Act clause therein. I agree that if I am a director/shareholder (owning at least 15% of the shares) of the Client I shall be personally liable for the performance of the Client's obligations under this contract.
Client Name *
Client Name
Witness Name *
Witness Name