Application details

Rep name
Please complete all sections.
Registered Company Name :* Trading name:*
Address details
Address 1:* Country/Region:*
Address 2: Country:
City:* Post code:*
Telephone No:* Fax No:
Contact number:

Delivery details (if different)

Address 1: Country/Region:
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

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?:*
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?:*

Bank Details

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:*