Date of Birth

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To Be Completed By Applicants -

Please complete all sections and read the Terms and Conditions of Trade overleaf.

PERSONAL INFORMATION

DETAILS OF OWNER (If Sole Trader) PARTNERS (If Partneship) OR DIRECTORS (If Company) Name:

Date of Birth:

Name:

Date of Birth:

Physical Address: Postal Address: Time at address:

Residence type: Own

Occupation:

☐

Rent

☐

Board

☐

Time in occupation:

Home Ph:

Mobile Ph:

Work Ph:

Email Address:

Legal Name:

Trading Name:

COMPANY DETAILS

Physical Address: Postal Address: Type of business: Company

☐

Sole Trader

☐

Partneship

☐ Other:

Email Address:

Work Ph:

How long in business:

Company Number:

Business Trade Reference 1: Business Trade Reference 2:

PRIVACY WAIVER STATEMENT

Bank:

Insurance:

I certify that the above information 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 & HIRE(overleaf) of Tractor and Machinery Hire 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 detailed in the Privacy Act clause therein. I agree that if I am a director or a shareholder (owning at least 15% of the shares) of the Customer I shall be personally liable for the performance of the Customer’s obligations under this contract.

Signed (Customer): WITNESS TO CUSTOMERS SIGNATURE

Signed: © Tractor and Machinery Hire Ltd - 2012 Tractor and Machinery Hire Ltd PO Box 133, WAVERLEY Ph 0275 258 152 Fax (06) 354 4455

Name:

Date: