Company Account Application Form

COMPLETION OF THIS FORM DOES NOT GUARANTEE A CREDIT ACCOUNT FACILITY; ALL APPLICATIONS ARE SUBJECT TO A CREDIT ASSESSMENT PROCEDURE

Company Details

Company Name

Trading Name (If different)

Delivery Address

Are there any delivery restrictions (Such as delivery times, gate codes, height restrictions)

Invoice Address If different to delivery address

Company Status

Company Registration No.

VAT Number

Registered Office If different to delivery or invoice address

Part of a Group

Other Account Numbers / Names with us?

Type of Account Required

Business Type

Ledger Contact Information

Name

Phone Number

Position

Delivery Contact Information

Name

Phone Number

Position

Ordering Contact Information

Name

Phone Number

Position

Trade References

Name

Contact Name

Phone Number

Address

Name

Contact Name

Phone Number

Address

Name

Contact Name

Phone Number

Address

Add

Legally Responsible Contacts To Be Completed By Trustees/Owners/Tenants/Members/Secretaries/Treasurers

Name

Position

Home Address

Phone Number

Date of Birth

Previous home address

If less than 1 year at current home address

Name

Position

Home Address

Phone Number

Date of Birth

Previous home address

If less than 1 year at current home address

Name

Position

Home Address

Phone Number

Date of Birth

Previous home address

If less than 1 year at current home address

Name

Position

Home Address

Phone Number

Date of Birth

Previous home address

If less than 1 year at current home address

Add

Declaration

the undersigned agree to the Terms and Conditions of trade and confirm that the information given is correct to the best of our knowledge.
further agree that unless confirmed in writing by Alliance Disposables Ireland Ltd, we will adhere to the payment terms of 30 days from date of invoice.

Signed

Clear Signature

Printed Name

Position

Phone Number

Email Address

Date Signed

Direct Debit

SEPA Direct Debit Mandate

Creditor Identifier

Alliance Disposables Ireland Ltd

Legal Text: By signing this mandate form, you authorise (A) Alliance Disposables Ireland Ltd to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instruction from Alliance Disposables Ireland Ltd.

As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.

Please complete all the fields below marked *

* Your Name

Your Address

* City / Postcode

* Country

* Account Number (IBAN)

* Swift BIC

* Creditors Name

* Creditors Address Line 1

* Creditors Address Line 2

* Country

* Type of Payment:

Recurrent

One Off Payment

* Date of Signing

Signed

Clear Signature

Please note that we may be in touch with any queries regarding your application

Alliance National is committed to protecting the privacy of individuals. If you provide us with personal details about yourself, we will NOT pass that information to any other third party unless required to do so by law. To find out more about how we use your personal information, please see our Privacy Policy.