Confidential Credit Application - Department of Primary Industries
Confidential Credit Application - Department of Primary Industries
Confidential Credit Application - Department of Primary Industries
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<strong>Confidential</strong> <strong>Credit</strong> <strong>Application</strong><br />
ABN 78 342 684 030<br />
Regional Use Only<br />
<strong>Department</strong>al Use Only<br />
Head Office Use Only<br />
Debtor Area No./Region<br />
Contact Officer’s name<br />
Telephone number<br />
<strong>Credit</strong> Limit Approved<br />
<strong>Credit</strong> Approval No.<br />
$<br />
Type <strong>of</strong> Business Operation (Tick applicable box, then complete the sections indicated for your selection)<br />
Sole Trader (one person operation) Complete sections 1, 2, 5, 6, 7.<br />
Section 1<br />
Partnership (husband and wife fall within this definition)<br />
Business / Company Complete sections 1, 4, 5, 6, 7.<br />
Complete sections 1, 3, 5, 6, 7.<br />
<strong>Credit</strong> Limit Sought $<br />
Date <strong>of</strong> <strong>Application</strong><br />
Applicant's Full Name (Include Trading Name if applicable)<br />
/ /<br />
Trading Address<br />
Invoice Address<br />
(if different to<br />
Trading Address)<br />
Delivery Address (if applicable)<br />
Phone Number<br />
( )<br />
Fax number<br />
( )<br />
Fax Number<br />
Section 2 - Sole<br />
Mr/Mrs/Miss/Ms<br />
Current<br />
Residential<br />
Address<br />
Date <strong>of</strong> Birth<br />
/ /<br />
(one person operation only)<br />
Given Name/s<br />
Driver's Licence No.<br />
Family Name<br />
Phone<br />
Number ( )<br />
Post Code<br />
Previous residential address if less<br />
than 3 years at current address<br />
Section 3 - Partnership<br />
Business Name<br />
ABN<br />
ABN<br />
Details <strong>of</strong> partner A<br />
Full name<br />
Address<br />
(Attach details if insufficient space)<br />
Period <strong>of</strong> time the partnership/<br />
business has been operating<br />
Date <strong>of</strong> Birth<br />
/ /<br />
Driver's Licence No.<br />
Phone Number<br />
( )<br />
Details <strong>of</strong> partner B<br />
Full name<br />
Address<br />
(Attach details if insufficient space)<br />
Date <strong>of</strong> Birth<br />
/ /<br />
Driver's Licence No.<br />
Phone Number<br />
( )<br />
Section 4 - Company<br />
ABN<br />
Name<br />
Address <strong>of</strong> Registered Office<br />
Period <strong>of</strong> time<br />
Company has<br />
been operating<br />
Company Contact<br />
Name<br />
Phone ( ) Fax ( )<br />
Post Code<br />
Form FDU 326 03/04 © State <strong>of</strong> Queensland 2004<br />
Forms Management Unit
Section 5 - References<br />
Bank<br />
Name<br />
Branch<br />
Other <strong>Credit</strong> Providers (Please list at least 3)<br />
Name <strong>of</strong> Person/Company Address Phone Number<br />
( )<br />
( )<br />
( )<br />
I/We hereby apply for the opening <strong>of</strong> a credit account with the <strong>Department</strong> <strong>of</strong> <strong>Primary</strong> <strong>Industries</strong> and Fisheries, and provide<br />
the foregoing information in support <strong>of</strong> this application.<br />
I/We understand that accounts when rendered are strictly net 30 days.<br />
I/We undertake to pay all accounts by the due date and acknowledge that if the account becomes overdue, the <strong>Department</strong> <strong>of</strong><br />
<strong>Primary</strong> <strong>Industries</strong> and Fisheries reserves the right to withdraw or vary such credit limits as deemed appropriate from time to<br />
time.<br />
I/We agree to observe the provisions <strong>of</strong> the Copyright Act 1968 (Commonwealth) as amended from time to time and<br />
undertake not to copy or reproduce in any form (written or otherwise) information, material, data or any other creation<br />
provided by the <strong>Department</strong> without first obtaining the written consent <strong>of</strong> the <strong>Department</strong>.<br />
I/We acknowledge receipt <strong>of</strong> and accept your General Terms and Conditions <strong>of</strong> Sale/Service.<br />
Section 6 - Signatures <strong>of</strong> Authorised Person/s<br />
If there is insufficient space for all signatories, please annex signatures to this application in the format, as set out below, which is<br />
appropriate to your business operation.<br />
Signature/s <strong>of</strong> Sole Trader or Partner/s authorised to sign on behalf <strong>of</strong> all Partners<br />
1 2<br />
Name<br />
(Please Print)<br />
Signature<br />
Witnessed by<br />
Name<br />
(Please Print)<br />
Signature<br />
Name<br />
(Please Print)<br />
Signature<br />
Witnessed by<br />
Name<br />
(Please Print)<br />
Signature<br />
Form FDU 326 03/04 Forms Management Unit
7Section 7<br />
Supplementary Authorities and Notice required in accordance with the Privacy Act 1988<br />
(Commonwealth), as amended from time to time, relating to this application for credit.<br />
1. Notice <strong>of</strong> Disclosure <strong>of</strong> your <strong>Credit</strong> Information to a <strong>Credit</strong> Reporting Agency.<br />
Under the Privacy Act 1988 (Commonwealth), as amended from time to time, a supplier may give<br />
a credit reporting agency personal information about your credit application. This information<br />
includes :<br />
(a)<br />
(b)<br />
(c)<br />
(d)<br />
(e)<br />
(f)<br />
(g)<br />
(h)<br />
Your name, date <strong>of</strong> birth, address, employer and driver's licence number.<br />
The fact that you have applied for credit and the amount.<br />
The fact that each supplier is a current credit provider to you.<br />
Payments overdue more than 60 days, and for which collection action has commenced.<br />
Advice that payments are no longer overdue.<br />
Cheques drawn by you that have been dishonoured more than once.<br />
In specified circumstances, that in the opinion <strong>of</strong> each supplier, you have committed a serious<br />
credit infringement.<br />
That credit provided to you by each supplier has been paid or otherwise discharged.<br />
2. I/We agree that :<br />
Each supplier may obtain from a credit reporting agency a credit report containing personal credit<br />
information (or a commercial credit worthiness report) about me/us in relation to commercial or<br />
personal credit provided by it.<br />
If considered relevant to collecting overdue payments for commercial credit provided to me/us,<br />
each supplier may receive from a credit reporting agency a credit report containing personal<br />
information about me/us in relation to collecting overdue payments.<br />
Each supplier may give to and seek from any credit providers named in this credit application and<br />
any credit providers that may be named in a credit report issued by a credit reporting agency<br />
information about my/our credit worthiness, credit standing, credit history or credit capacity that<br />
credit providers are allowed to give or receive from each other under the Privacy Act 1988<br />
(Commonwealth).<br />
3.<br />
.<br />
.<br />
I/We understand that the information may be used for the following purposes :<br />
To assess an application by me/us for credit.<br />
To notify other credit providers <strong>of</strong> a default by me/us.<br />
To exchange information with other credit providers as to the status <strong>of</strong> this application where I<br />
am in default with other credit providers.<br />
To assess my/our credit worthiness.<br />
Signatures <strong>of</strong> Applicants<br />
Date<br />
/ /<br />
Signatures <strong>of</strong> Applicants<br />
Date<br />
/ /<br />
/ /<br />
/ /<br />
Form FDU 326 03/04 Forms Management Unit