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Existing Customer No. :
(NB: Your application will be processed and you will be advised
when your secure login ID has been activated)
Fields marked * are mandatory  
  DETAILS OF APPLICANT
 
Title :
*
First Name :
*
Surname :
*
Registered Trading Name :
*
Address :
Country :
Postcode :
Position in the company :
*
Telephone :
*
Mobile :
Fax :
Email :
*
Website :
  DETAILS OF BUSINESS
* Business Type :
Partnership
Sole Trader
Limited Company
Company Registration No.:
No. of years Established :
Proprietors Full Name :
*
Address :
Country :
Postcode :
Telephone :
*
  Credit Requirements
   
Amount of Monthly credit required:
*
Do you anticipate trading with us :
Regularly Occasionally
   
  References
Please provide full names and addresses of two independent trade references with whom you have/ had credit facilities of over one year. Do not include companies who allow discount for prompt settlement.
   
Full Name :
*
Address :
Telephone :
*
   
Full Name :
*
Address :
Telephone :
*
Bank Details
 
Name :
*
Address :
Account No. :
*
Sort Code :
*
Years with Bank :
  Login Infomation
Login id :
* (Enter your preferred login id)
Password :
* (Maximum 8 characters)
Confirm Password :
 *
 
(The following information will be used in order to retreive/ reset your password)
Password Retreival Question :
 *
Create your own password retreival question :
Answer :
 *
 
(NB: Your application will be processed and you will be advised
when your secure login ID has been activated)
 
© 2004 Chemilines Limited.
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