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AUTHORISED RESELLER APPLICATION FORM

Please complete the following section to assist DataWorld Australia in evaluating your application. Thank you.

COMPANY DETAILS

Full company name:

Trading Name:

A.B.N:

Street Address:

Suburb:

State:

Postcode

Mobile No:

Phone No:

Email Address:

Website Address:

Postal address

If different, type in below

Address:

Suburb:

State:

Postcode:

NATURE OF COMPANY SET-UP

Entity Type:

Turnover Last Financial Year:

Estimated Turnover this financial year:

Estimated monthly spend with Dataworld Pty Ltd:

Anticipated Credit Limit Required:

Anticipated Credit terms:

DIRECTORS’ PARTICULARS

Director 1

Name:

Residential Address:

Residential Phone/Mobile:

Director 2

Name:

Residential Address:

Residential Phone/Mobile:

Director 3

Name:

Residential Address:

Residential Phone/Mobile:

Director 4

Name:

Residential Address:

Residential Phone/Mobile

ACCOUNTANT’S PARTICULARS

Name:

Address:

Phone:

COMPANY PREMISES

Type:

PRINCIPLE BUSINESS PREMISES

Specify if other:

Size:

sq.m.

No. of years at present location:

BRANCH LOCATION (S)

Branch 1

Street Address:

Suburb:

State:

Postcode:

Branch 2

Street Address:

Suburb:

State:

Postcode:

Branch 3

Street Address:

Suburb:

State:

Postcode:

Branch 4

Street Address:

Suburb:

State:

Postcode:

Branch 5

Street Address:

Suburb:

State:

Postcode:

TRADE REFERENCES

ONLY COMPLETE IF APPLYING FOR A TERM ACCOUNT

First Trade Reference

Name of Company:

Phone Number:

Email Address:

Person to Contact:

Trading History with Credit Reference:

Yrs

Credit Limit Provided:

Credit Terms:

Days

Usual Trade Volume/Month:

Second Trade Reference

Name of Company:

Phone Number:

Email Address:

Person to Contact:

Trading History with Credit Reference:

Yrs

Credit Limit Provided:

Credit Terms:

Days

Usual Trade Volume/Month:

Third Trade Reference

Name of Company

Phone Number:

Email Address:

Person to Contact:

Trading History with Credit Reference:

Yrs

Credit Limit Provided:

Credit Terms:

Days

Usual Trade Volume/Month:

Terms & Conditions

Click here to review Terms & Conditions

Terms and conditions acceptance

I have read and accept terms and conditions

Name:

Position:

Date: