Confidential Credit Application - Department of Primary Industries

Confidential Credit Application
ABN 78 342 684 030
Regional Use Only
Departmental Use Only
Head Office Use Only
Debtor Area No./Region
Contact Officer’s name
Telephone number
Credit Limit Approved
Credit Approval No.
$
Type of Business Operation (Tick applicable box, then complete the sections indicated for your selection)
Sole Trader (one person operation) Complete sections 1, 2, 5, 6, 7.
Section 1
Partnership (husband and wife fall within this definition)
Business / Company Complete sections 1, 4, 5, 6, 7.
Complete sections 1, 3, 5, 6, 7.
Credit Limit Sought $
Date of Application
Applicant's Full Name (Include Trading Name if applicable)
/ /
Trading Address
Invoice Address
(if different to
Trading Address)
Delivery Address (if applicable)
Phone Number
( )
Fax number
( )
Fax Number
Section 2 - Sole
Mr/Mrs/Miss/Ms
Current
Residential
Address
Date of Birth
/ /
(one person operation only)
Given Name/s
Driver's Licence No.
Family Name
Phone
Number ( )
Post Code
Previous residential address if less
than 3 years at current address
Section 3 - Partnership
Business Name
ABN
ABN
Details of partner A
Full name
Address
(Attach details if insufficient space)
Period of time the partnership/
business has been operating
Date of Birth
/ /
Driver's Licence No.
Phone Number
( )
Details of partner B
Full name
Address
(Attach details if insufficient space)
Date of Birth
/ /
Driver's Licence No.
Phone Number
( )
Section 4 - Company
ABN
Name
Address of Registered Office
Period of time
Company has
been operating
Company Contact
Name
Phone ( ) Fax ( )
Post Code
Form FDU 326 03/04 © State of Queensland 2004
Forms Management Unit

Section 5 - References
Bank
Name
Branch
Other Credit Providers (Please list at least 3)
Name of Person/Company Address Phone Number
( )
( )
( )
I/We hereby apply for the opening of a credit account with the Department of Primary Industries and Fisheries, and provide
the foregoing information in support of this application.
I/We understand that accounts when rendered are strictly net 30 days.
I/We undertake to pay all accounts by the due date and acknowledge that if the account becomes overdue, the Department of
Primary Industries and Fisheries reserves the right to withdraw or vary such credit limits as deemed appropriate from time to
time.
I/We agree to observe the provisions of the Copyright Act 1968 (Commonwealth) as amended from time to time and
undertake not to copy or reproduce in any form (written or otherwise) information, material, data or any other creation
provided by the Department without first obtaining the written consent of the Department.
I/We acknowledge receipt of and accept your General Terms and Conditions of Sale/Service.
Section 6 - Signatures of Authorised Person/s
If there is insufficient space for all signatories, please annex signatures to this application in the format, as set out below, which is
appropriate to your business operation.
Signature/s of Sole Trader or Partner/s authorised to sign on behalf of all Partners
1 2
Name
(Please Print)
Signature
Witnessed by
Name
(Please Print)
Signature
Name
(Please Print)
Signature
Witnessed by
Name
(Please Print)
Signature
Form FDU 326 03/04 Forms Management Unit

7Section 7
Supplementary Authorities and Notice required in accordance with the Privacy Act 1988
(Commonwealth), as amended from time to time, relating to this application for credit.
1. Notice of Disclosure of your Credit Information to a Credit Reporting Agency.
Under the Privacy Act 1988 (Commonwealth), as amended from time to time, a supplier may give
a credit reporting agency personal information about your credit application. This information
includes :
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Your name, date of birth, address, employer and driver's licence number.
The fact that you have applied for credit and the amount.
The fact that each supplier is a current credit provider to you.
Payments overdue more than 60 days, and for which collection action has commenced.
Advice that payments are no longer overdue.
Cheques drawn by you that have been dishonoured more than once.
In specified circumstances, that in the opinion of each supplier, you have committed a serious
credit infringement.
That credit provided to you by each supplier has been paid or otherwise discharged.
2. I/We agree that :
Each supplier may obtain from a credit reporting agency a credit report containing personal credit
information (or a commercial credit worthiness report) about me/us in relation to commercial or
personal credit provided by it.
If considered relevant to collecting overdue payments for commercial credit provided to me/us,
each supplier may receive from a credit reporting agency a credit report containing personal
information about me/us in relation to collecting overdue payments.
Each supplier may give to and seek from any credit providers named in this credit application and
any credit providers that may be named in a credit report issued by a credit reporting agency
information about my/our credit worthiness, credit standing, credit history or credit capacity that
credit providers are allowed to give or receive from each other under the Privacy Act 1988
(Commonwealth).
3.
.
.
I/We understand that the information may be used for the following purposes :
To assess an application by me/us for credit.
To notify other credit providers of a default by me/us.
To exchange information with other credit providers as to the status of this application where I
am in default with other credit providers.
To assess my/our credit worthiness.
Signatures of Applicants
Date
/ /
Signatures of Applicants
Date
/ /
/ /
/ /
Form FDU 326 03/04 Forms Management Unit