Mirage Stellar

Dublin - White

Dublin - Blend

Dublin - Flax

Dublin - Charcoal

Dublin - Denim

COMPANY DETAILS

Type of Company*CCPTYSole ProprietorPartnership

Registered Company Name*

Trading Name*

Registered Business Address*

Delivery Address*

Postal Address

Reg Number*

VAT Number

Accounts Email*

Telephone Number*

Fax Number*

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KEY CONTACTS

Accounts Person Name*

Accounts Email*

Accounts Tel*

Buyer Name*

Buyer Email*

Buyer Tel*

Financial Manager*

Financial Email*

Financial Tel*

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BANKING DETAILS

Bank Account Name*

Type of Account*

Name of Bank*

Branch Code*

Account Number*

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DIRECTOR/MEMBER/OWNER DETAILS

Director 1 Name*

Director 1 ID Number*

Director 1 Cell Number*

Director 1 Email*

Director 2 Name

Director 2 ID Number

Director 2 Cell Number

Director 2 Email

Director 3 Name

Director 3 ID Number

Director 3 Cell Number

Director 3 Email

Director 4 Name

Director 4 ID Number

Director 4 Cell Number

Director 4 Email

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TRADE REFERENCES (All clients to complete please)

Reference 1
Company Name*

Contact Person*

Contact Number*

Facility Value

Reference 2
Company Name

Contact Person

Contact Number

Facility Value

Reference 3
Company Name

Contact Person

Contact Number

Facility Value

Reference 4
Company Name

Contact Person

Contact Number

Facility Value

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DecoratorCurtain MakerUpholstererBuyerManufacturerOther

If other, please specify

Would you like us to appoint a consultant to keep in contact with you?
YesNo

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TERMS AND CONDITIONS

Orders will only be placed on receipt of a official company purchase order.
Where fabric is cut and then cancelled a surcharge of 20% will be applicable.
All new accounts are opened on COD basis.

Name*

ID Number*

Date*

By ticking this checkbox, you confirm that you are duly authorised to accept the trading terms and to sign of on behalf of the abovementioned company. You also accept terms and conditions as set above and all information supplied is correct.*
Yes

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