HEALTH  REVOLUTION  PTY  LIMITED,  ABN:      42  155  684  843    

APPLICATION  FOR  COMMERCIAL  CREDIT     I/we  hereby  apply  for  credit  and  submit  the  following  confidential  information  for  this  purpose  only.     NAME  AND  ADDRESS  OF  BUSINESS       Trading  Name       Trading  Address                                                                                                                                   Postcode       Postal  Address         Postcode         Telephone   Facsimile                 Date  Commenced                                            Email       Trading           Number  of  employees         Contact  Name  for  Account  Queries       Contact  Phone  Number     PARTICULARS  OF  COMPANY/SOLE  TRADER/PARTNERSHIP/CO-­‐OPERATIVE     (Strike  out  that  which  does  not  apply)     COMPANY/SOLE  TRADER/  PARTNERSHIP/CO-­‐OPERATIVE     Full  Name  of  Company/  Sole  Trader/         Partnership/Co-­‐operative  applying   for  credit  (“Applicant”)                                                                             If  a  company  or  co-­‐operative:       Registered  Office                   If  company     ABN  No:   Date  of  Incorporation:          

Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029

Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

  APPLICATION  FOR  COMMERCIAL  CREDIT  

If  co-­‐operative   Registration  No:       AUTHORISED  PURCHASING  OFFICER     Name         Title   Contact  phone     number     TRADE  REFERENCE         1   Supplier  Name         Address         Telephone             TRADE  REFERENCE       2   Supplier  Name       Address       Telephone        

  Date  of  Registration:  

       

       

       

      Terms:  Payment  CBD  (Cash  Before  Delivery)  for  the  1st  order.  The  1st  instalment  will  be  paid  via   credit  card  or  eft  the  day  the  order  is  placed.  Subsequent  purchases  are  due  for  payment  30  Days   from  the  Invoice  date  after  credit  is  approved.  Credit  facilities  may  be  withdrawn  or  varied  by  Health   Revolution  if  these  terms  are  ignored.  Health  Revolution  reserves  the  right  to  charge  interest  at  the   rate  of  1.5%  per  month  on  overdue  monies  and  the  purchaser  agrees  to  reimburse  Health   Revolution  for  any  legal  expenses  incurred  in  the  recovery  or  attempted  recovery  of  such  monies.   Cheques  and  payments  shall  be  made  payable  to  the  company.  Payments  by  cheque  shall  not  be   deemed  made  until  the  cheques  have  been  cleared.     Where  you  are  in  default  of  Health  Revolution  Terms  and  Conditions,  Health  Revolution  reserves  all   of  its  rights  under  the  PPSA,  including  the  right  to  recover  goods  and  money  secured.  Words  and   expressions  which  have  a  defined  meaning  in  the  PPSA  have  the  same  meaning  when  used  in  Health   Revolution  Terms  and  Conditions.          
Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029 Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

  APPLICATION  FOR  COMMERCIAL  CREDIT  

 CREDIT  CARD  AUTHORISATION    -­‐  please  tick  if  applicable  for  1st  payment     ACCOUNT  DETAILS     Account  Name  _____________________________________________________________________     Name  one  card  _____________________________________________________________________     Credit  Card  Type____________________________________________________________________     Credit  Card  Number  _________________________________________________________________     Expiry  Date_________________________________________________________________________    
Visa and Master Cards attract a 1% surcharge. Amex and Diners 2.7%

     EFT  BANK  TRANSFERS  –  please  tick  if  applicable  for  1st  payment.       Health  Revolution  Pty  Ltd  -­‐  ABN  42  155  684  843     Bank  Account:  BSB  #  012281              Account  #  530459388     The   Applicant   acknowledges   that   he/she   has   received   a   copy   of   the   Health   Revolution   Pty   Limited   terms  and  conditions  prior  to  him/her  signing  this  application.  The  person(s)  signing  this  application   warrants   that   he/she   has   read   and   fully   understands   the   nature   and   effect   of   the   terms   and   conditions,  and  has  the  authority  to  sign  on  behalf  of  the  Applicant  and  the  information  provided  is   true  and  correct  in  every  detail.               Signed   Date                                    
Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029 Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

  APPLICATION  FOR  COMMERCIAL  CREDIT  

    Debtor  Code       Trade  References  Checked  :       1       2       3     Authorisation  to  open  this  account  has  been       Approved  credit  limit     Signed  ___________________________________        

  HEALTH  REVOLUTION  PTY  LTD   Office  use  only    

     GRANTED        $2,000.00     Date  __________        

DECLINED  

Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029

Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

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