Reset Form

Tel: 02 6279 0153

Fax: 02 6248 8053

NEW SUPPLIER REQUEST / AMENDMENT FORM

For use by local Australian suppliers only

Print Form

51 Allara Street
Canberra City
GPO Box 1801
Canberra ACT 2601

For purchases:
- less than $5,000, payment by credit card is preferred.
- $5,000 or greater, payment will be made to the supplier by electronic funds transfer (EFT).
- for amounts $5,000 or greater, a purchase order (PO) will be emailed to the supplier; the PO number
must be quoted in all correspondence.
ANY QUERIES PLEASE E-MAIL finance@mdba.gov.au
CONTACT Accounts Payable Clerk on 02 6279 0153

Supplier name
Trading name: ..........................................................
ABN: ........................................................................
Commonwealth Agency: Yes

New application
Amendment

No

Business Type: Government

Individual

Large Business (> 20 employees)

Small Business (< 20 employees)

Purchase Order
E-mail address: ..........................................................................................................................................
Contact information
For Accounts
For Contracts
Street Address: ........................................................
Street Address: ..................................................
Suburb: .....................................................................
Suburb: ..............................................................
City: ..........................................................................
City: ...................................................................
State: .......................................................................
State: .................................................................
Postcode: .................................................................
Postcode: ...........................................................
Phone number: ........................................................
Fax number: .............................................................
Contact name: .........................................................
Payment information
EFT details
Name of financial institution: ....................................
Account name: .........................................................

BSB number (six digits): ....................................

Account number: ...............................................

Remittance advice
E-mail address: ........................................ ..................................................................................... .............
AUTHORISATION - By Authorised Officer of Supplier (Please sign and return by fax to 02 6248 8053, marked
Attention: Finance)

Signed: .....................................................................
Full Name: ...............................................................

Date: ..................................................................
Position: .............................................................

MURRAY-DARLING BASIN AUTHORITY use only

MDBA Officer Requested Form: ..............................
Date Received by Finance: ......................................

Date: ..................................................................

1 of 1

New Supplier Request/Amendment Form 040609