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Company Name (required) [text* company-name]
Address 1 [text Address2]
City [text City]
County [text County]
Post Code (required) [text* County]
Telephone (required) [text* Telephone]
Fax [text Fax]
Email (required) [text* Email]
Main Business Activity [text Main-Business-Activity]
VAT Number [text VAT-Number]
Limited Companies
If you are completing this form as a Limited Company all fields in this section must be completed
Registered Number [text RegisteredNumber]
Date of Incorporation [text DateofIncorporation]
Date Business Commenced [text DateBusinessCommenced]
Registered Name [text RegisteredName]
Registered Office [text RegisteredOffice]
Partnerships / Sole Traders
– Name & Private Addresses of proprietor / partners
Name 1 [text Name1]
Address 1 [text addressone]
Name 2 [text Name2]
Address 2 [text addresstwo]
Name 3 [text Name3]
Address 3 [text Address3]
Name 4 [text Name4]
Address 4 [text Address4]
Date business commenced [text Datebusinesscommenced]
Bank Details
Should you not wish to open a credit account with us please tick this box to confirm that any order placed will be paid by Credit Card (or other means of cleared funds) prior to despatch [checkbox Bankdetailstickbox “Tick here, if not fill in your Bank details below”]
Name [text NameBank]
Address [text Addressbank]
Sort Code [text SortCode]
Account Number [text AccountNumber]
Trade References
– Please supply details of two suppliers with whom you have at least 6 months history who we can contact as part of our credit approval process.
Name 1 [text NameTrade]
Address [text AddressTrade]
Tel [text TelTrade]
Name 2 [text NameTrade2]
Address [text AddressTrade2]
Tel [text TelTrade2]
Credit Details
Credit Required (£) (required) [text* CreditRequired]
Accounts Contact (required) [text* AccountsContact]
Tel (required) [text* TelCredit]
Email (required) [text* EmailCredit]
Authorisation Contact (required) [text* AuthorisationContact]
Do You Operate A Purchase Order System? [radio DoYouOperateAPurchaseOrderSystem label_first default:1 “Yes” “No”]
Which C3 branch are you setting an Account up with?
Please indicate your closest branch [select* Pleaseindicateyourclosestbranch include_blank “South Wales” “Colchester” “Liverpool” “London”]
Name of C3 Rep contact [text* NameofC3Repcontact]
Terms & Conditions
– Only to be clicked and agreed to by an Officer of the company. We agree to the terms and conditions of C3imaging. The credit terms are 30 days nett monthly.
Agree to Click Terms & Conditions [radio termsaccept label_first default:1 “Yes” “No”]
Name (required) [text* NameTerms]
Position (required) [text* Position]