Eclipse

Company Details Applicant Details Trade Reference Customer Declaration Terms and Conditions

Company Name

Invoice Address

Country

Postcode

VAT Reg No

Delivery Address Same As Invoice?

Email Address (Accounts)

Email Address (Sales)

Phone Number

Legal Status of Applicant

If you want to pay direct debit, click here

Relationship to Applicant

Partner 1

Forename

Surname

Date Of Birth

Address

Country

Postcode

National Insurance Number

Number of Years at Address

Add Partner 2

Partner 2

Forename

Surname

Date Of Birth

Address

Country

Postcode

National Insurance Number

Number of Years at Address

Have You Traded With [Trade Business] Before?

Standard Reference Procedures

[Standard Reference Procedures]

I acknowledge that I have read and agree to the Standard Reference Procedures

Forename

Surname

Address

Country

Postcode

Email Address

Fax Number

Phone Number

Add second trade reference

Please advice whether you/the applicant, has ever been subject to the following?

Individual Voluntary Arrangement

Bankruptcy

Administration Order

Winding Up Order

Company Voluntary Arrangement

County Court Judgement

If you have selected any of the above, please provide brief details of the amount, date and whether the action has been satisfied

Action

Date

Amount

Date Satisfied

Action

Date

Amount

Date Satisfied

[Terms and Conditions]

I acknowledge that I have read and agree to the Terms and Conditions

I confirm that all information as provided in this application is accurate and complete to the best of my knowledge

I confirm I am authorised to complete the application on behalf of the company

[RECPATCHA]

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