Initial here: CREDIT APPLICATION FORM (04/15) Fax together with

CREDIT APPLICATION FORM (04/15)
Fax together with your ID to 021-510 1322 or 086 581 1930
CONFIDENTIAL
FOR OFFICE USE:
Name of Account
Account Number
DIRECTORS / PARTNERS / MEMBER DETAILS
Surname
First Name
Initials
ID Number
Gender
Cell Number
Surname
Initials
ID Number
First Name
Gender
Cell Number
Surname
Initials
ID Number
First Name
Gender
Cell Number
COMPANY DETAILS
Registered Name
Trading Name
Business Registration Number
VAT Registration Number
Business Physical Address
Practice Number
Telephone Number
Fax Number
E-mail address
Province
Postal Code
Business Postal Address
Province
Postal Code
Initial here:
CREDIT APPLICATION FORM
ACCOUNTS INFORMATION
Name & Address of Accountant
Contact person
E-mail address for account queries / statements
BANKING DETAILS
Bank
Branch code
Account Number
Account Name & Type
Have you ceded your debtors? (If so, to whom?)
FIXED ASSETS
Fixed property owned by Directors or Partners
Description
Value
Amount
Fixtures, Fittings and Equipment: Value
Is it leased / Instalment Sale / Unencumbered?
Amount of lease, etc. owing
Name and address of landlords
Yes / No
Bondholder
TRADE REFERENCES
Company Name
Account Number
Average Monthly
Purchases
Outstanding balance
OTHER
Estimated monthly purchases:
Amount of credit required:
MARKETING INFORMATION
We would like to communicate special offers and keep you informed about news and product info.
Please advise the e-mail address you would like us to use:
FOR OFFICE USE ONLY
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CREDIT APPLICATION FORM
TERMS AND CONDITIONS
1. Payment terms are strictly within 25 days from date of statement.
2. The Applicant agrees that should any portion of an invoice be in dispute, the Applicant undertakes to pay the
undisputed amount of the invoice to the agreed terms of credit allowed in terms of this agreement.
3. Uber Optical shall be entitled to charge interest on all overdue amounts at a compound rate of 3% per annum
above the prime bank overdraft rate as charged by Uber Optical’s bankers.
4. The Applicant agrees that in the event of its default in any respect whatsoever towards Uber Optical, Uber
Optical will be entitled to place the Applicants account on hold and withhold any further supply without any
notice notwithstanding that the Applicant may have placed an order prior rot the account being put on hold.
5. All the goods remain the sole and absolute property of Uber Optical until full payment has been received by
Uber Optical in respect of any goods supplied to the Applicant.
6. In the event of Uber Optical instructing its attorneys to collect any amounts, all legal fees and collection charges
and all other costs incurred will be borne by the Applicant on an attorney and own client scale.
7. It is up to the discretion of Uber Optical whether to accept the return of goods for credit from the Applicant.
8. If the goods were correctly supplied by Uber Optical and were not faulty or subject to any claim, then Uber
Optical will be entitled without the necessity of any further agreement to claim a handling fee of 20% of the
invoice price of the goods returned should the goods not be returned in good order and in the original
packaging.
9. The applicant agrees to the Goods Return Policy as stated on the Uber Optical form.
10. The credit facilities may be withdrawn by Uber Optical at any time without prior notice.
11. The Applicant/s choose the addresses provided by it/them in this Credit Application as domicilium citandi et
executandi for the purposes of service of all legal notices and process arising out of this Credit Application.
12. In the event that legal action needs to be taken for any sums outstanding in terms of this Credit Application, the
Applicant Consents to the Jurisdiction of the Cape Town Magistrates court.
13. Both the Applicant and Uber Optical confirm that the Credit Application constitutes the entire agreement
between the parties; any amendment, cession of rights by the Applicant, or any other form of variation of this
agreement will be of no force and effect unless reduced by writing and signed by all of the parties.
DECLARATION
The Applicant acknowledges that Uber Optical may access any information recorded with any credit bureau and any
information relating to the utilisation and / or non-compliance with the terms of the Agreement, and the Applicant
agrees that the terms of the Agreement and termination thereof (and the reasons therefore) may be disclosed to and
used by any credit bureau. A credit bureau provides a credit profile on persons as well as possible a credit score on
the credit worthiness of persons. It is recorded that the Applicant has the right to contact any credit bureau to have
its credit record disclosed and to correct any inaccurate information.
I, ______________________________________, acknowledge having read the terms and conditions, without
limiting the generality thereof, and agree to abide by all such terms and conditions and acknowledge that the
information furnished above is true and correct in every respect.
Applicant’s signature:
Capacity:
Print Name:
Date:
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