New Client form

Credit account application Form

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

To download a PDF/printable copy of this form, please click here.

Customer Details

Customer Type

Full or Legal Name

Physical Address

Billing Address

Email Address

Phone Number

Mobile Number

Personal Details

Please complete if you are an individual

Date of Birth

Driver Licence Number

Business Details

Please complete if you are a Sole Trader, Trust, Partnership, Company or Other – as specified

Trading Name

GST Number

If applicable

Company Number

Date Incorporated

Current owners

Nature of Business

Directors / Owners / Trustee #1

If more than two, please email a separate sheet to echd@echd.co.nz.

Full Name

Date of Birth

Private Address

Driver's Licence Number

Phone Number

Mobile Number

Directors / Owners / Trustee #2

If more than two, please email a separate sheet to echd@echd.co.nz.

Full Name

Date of Birth

Private Address

Driver's Licence Number

Phone Number

Mobile Number

Declaration

I certify that the above information is true and correct and that I accept the supply of credit by ECHD (if applicable). I have read and understand the TERMS AND CONDITIONS OF TRADE (linked above this form) of East Coast Heavy Diesel & Machinery Limited which form part of, and are intended to be read in conjunction with this Customer Information Form 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/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)

Click here to sign & agree to TOT

Full Name

Position

Date

YYYY

New Client form

Credit account application Form

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