Lindsay and Dixon

APPLICATION FOR SUPPLY OF GOODS

To: Lindsay & Dixon Limited ("L & D")

The Applicant recorded below ("the Applicant"), requests the supply of goods from L & D.

If L & D agrees to supply the Applicant, then the Applicant agrees that such supply shall be on the Terms & Conditions as shown here. The term "Customer" in the Terms and Conditions shall be a reference to the Applicant. The Applicant acknowledges that it has read, understood, and accepted the Terms and Conditions. The Applicant agrees that L & D may disclose this application to a third party in accordance with the privacy and personal information terms set out in the said Terms and Conditions.

To ensure that your application is processed quickly, please supply as much information as possible.

Name of Applicant

Address for correspondence / notices:

Street Address for delivery of goods:

City

Telephone Number:

Facsimile Number:

Mail from (Your email Address):

Trade Referees 1

Trade Referees 2

Type of Business

The Applicant is a Limited Company
The Applicant is a Partnership

If the Applicant is a Company, state the names of the Directors

GUARANTEE (to be checked if the Applicant is a company)

I / We agree that in consideration of Lindsay & Dixon Limited ('L & D') supplying goods to the Applicant at my / our request, I / we jointly and severally guarantee to L & D the due and punctual payment by the Applicant of all monies owed to L & D, and punctual performance and observance by the Applicant of the Terms and Conditions.

If the Applicant is a partnership, state the names of the other partners

Additional Comments

NOTE: By submitting this form you agree to and accept the Terms & Conditions and will be considered the same as physically signing an Application form.

I agree to and accept the above terms