Chemilines
Registration
Application details
Rep name
Please complete all sections.
Registered Company Name :*
Trading name:*
Address details
Address 1:*
Country/Region:*
Select
United Arab Emirates
ANGOLA
Austria
Australia
Belgium
Bulgaria
Brazil
Canada
Switzerland
Cyprus
Czech Republic
Germany
Denmark
Algeria
Estonia
Greece
Spain
EU countries
Finland
France
United Kingdom
GHANA
Greece
Croatia
Hungary
Indonesia
Ireland
India
Iceland
Italy
Kenya
Lithuania
Latvia
Morocco
MALTA
Mexico
Malaysia
Mozambique
Nigeria
The Netherlands
Norway
Netherlands/Holland
New Zealand
Philippines
Poland
Portugal
Romania
Russia
Sweden
Singapore
Slovenia
Slovakia
Switzerland
Thailand
Tunisia
Turkey
Tanzania
Uganda
United Kingdom
USA
South Africa
Address 2:
Country:
City:*
Post code:*
Telephone No:*
Fax No:
Contact number:
Delivery details (if different)
Address 1:
Country/Region:
Select
United Arab Emirates
ANGOLA
Austria
Australia
Belgium
Bulgaria
Brazil
Canada
Switzerland
Cyprus
Czech Republic
Germany
Denmark
Algeria
Estonia
Greece
Spain
EU countries
Finland
France
United Kingdom
GHANA
Greece
Croatia
Hungary
Indonesia
Ireland
India
Iceland
Italy
Kenya
Lithuania
Latvia
Morocco
MALTA
Mexico
Malaysia
Mozambique
Nigeria
The Netherlands
Norway
Netherlands/Holland
New Zealand
Philippines
Poland
Portugal
Romania
Russia
Sweden
Singapore
Slovenia
Slovakia
Switzerland
Thailand
Tunisia
Turkey
Tanzania
Uganda
United Kingdom
USA
South Africa
Address 2:
Country:
City:
Post code:
Telephone No:
Fax No:
Primary Contact No :
Other details
Ltd Company Registration No:
VAT No:*
Wholesale Dealers License No :
E-mail:*
(will be used as your Login Id)
Details of Business
Plc
Sole Trader
Limited Company
Partnership
Type of Business:*
No of Branches:*
(Please attach a list)
Years Established:*
Full Names of Shareholders / Partner / Sole Proprietor of the Company:
*
Full Names of Directors of Company:*
Address 1:*
Address 2:*
Country:*
City:*
Post code:*
Telephone No:*
Mobile No:*
Fax No:*
Email:*
Other details
Copy of Wholesale Dealers Licence supplied?:*
Yes
No
Contact Name in Accounts Department:*
Fax No:
Position:*
Mobile No:
Telphone No:*
E-mail:
Credit Requirements
Amount of monthly credit required:*
Do you anticipate trading with us?:*
Regularly
Occasionally
Bank Details
Name:
Address 1:
Address 2:
Telephone No:
Bank Account No:
Fax No:
Sort Code:
We request a credit account to be opened in our name agree to the terms and conditions laid down by Chemilines Limited. We authorise you to seek references from the above companies and bank.
Name of the person completing this form:*
Position: