LIBERTY MOTOR ASSOCIATES (PVT) LTD.

No. 488, Sri Sangaraja Mw., Colombo 10. Tel : 011-2445407 Fax : 011-2446454

CUSTOMER REGISTRATION FORM

** Applicable ONLY for CREDIT CUSTOMERS

Company Name________________________________________ Date of Application _______________

Registered Address _____________________________________________________________________
Billing Address ________________________________________________________________________
Telephone _________________ FAX ____________________

Type of Business_______________________________________ In Business Since _________________

Type of Company (Pls.mark X)
Limited Liability Partnership
Public Limited Sole Proprietor
Company Registration No ___________________ ( **Pls attached the copy of certificate)
VAT No ______________________________
SVAT No ______________________________ ( Pls attached the copy of SVAT certificate)

Payment Terms (Pls mark X) Credit Cash

**If Credit, Payment Type (Pls mark X) Cheque Cash Cheque issuing period __________

Cash Payment Method (Pls mark X) Direct Bank Deposits Handed over

**If Credit, Requested credit Period ______________ Requested credit Limit (Rs.) ________________

Authorized Person for Purchases ___________________________________________________________

Designation______________ Contact No_____________ Fax ___________ Email__________________

Contact Person for Payments ______________________________________________________________

Designation______________ Contact No_____________ Fax ___________ Email__________________

Contact Person for Head of Finance _________________________________________________________

Designation______________ Contact No_____________ Fax ___________ Email__________________

Contact Person for SVAT ________________________________________________________________

Designation______________ Contact No_____________ Fax ___________ Email__________________

** Undertaking Applicant
In consideration of a credit account granted by “Liberty Motor Associates (Pvt) Ltd.” I/ We hereby
agree to settle your account promptly, as per agreed terms. If I/We fail to settle the account on time
Liberty Motor Associates (Pvt) Ltd will have the liberty to take necessary action required to recover
amounts remaining unsettled for more than the time allowed to settle the outstanding.

………………………………………………..
Authorized Signature (Sign on the Company Rubber Stamp)
NAME _________________________________________________________________
DESIGNATION _________________________________________________________
DATE ________________________