Wholesale & Retail Account Application

Applicant

Applicant Name:*

Company Registration Number (NZBN or Equivalent):*

Trading Name:*

Statement/Invoice Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Statement/Invoice Email Address:*

Enter Email Confirm Email

Physical Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accounts Department Contact

Accounts Department Contact Name:*

Landline Phone Number*

Mobile Phone Number*

Email*

Enter Email Confirm Email

Sales Contact

Sales Contact Name:*

Mobile Phone Number

Landline Phone Number*

Email*

Enter Email Confirm Email

Directors/Proprietors

Directors/Proprietors Names Home Address:*

Credit References: Phone Number:*

Consent*

I agree

Acceptance of Terms and Conditions of Trade I/We hereby apply to open a credit account with Mipuchi New Zealand. I/We have already read and fully understand Mipuchi New Zealand Ltd Terms and Conditions of Trade and agree to abide by them.

Name of the person signing the application:*

Position Held*

Date*

Signature*

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Wholesaler & Retailer Account Application

Create An Account

Applicant

Accounts Department Contact

Sales Contact

Directors/Proprietors

Become a MiEqui VIG (Very Important Groomer)