Your name (required)

Your business address (required)

Years trading at address (required)
0-11-33-55-1010 +

Address of registered office - if a Ltd company (required)

Company number (required)

Telephone number (required)

Fax number (if applicable)

Your email (required)

Business Status - please select one (required)
Sole traderPartnershipLimited liability partnershipLimited company

References

Reference 1 - Please include name, address, and telephone number (required)

Reference 2 - Please include name, address, and telephone number (required)

Banking details - Please include account title and bank address (required)

Proprietors, partners, directors details.

Person 1 - Please include name, address, and telephone number (required)

Person 2 - Please include name, address, and telephone number (if applicable)

Person 3 - Please include name, address, and telephone number (if applicable)

Does anyone listed above own, is a director, or is associated with other companies?

Please give details (required)

Any further information (optional)

STATEMENT OF ACCEPTANCE OF TERMS OF APPLICANT:

I/We apply for credit facilities with Mosella UK Ltd subject to their Standard Terms and Conditions, a copy of which I/We acknowledge receipt, and I/We undertake to pay each invoice by the due date.

I/We hereby consent to the processing by Mosella UK Ltd and/or on their behalf by the agents of such data as are contained in the Credit Account Application form and any associated documentation in accordance with requirements of the Data Protection Act 1968 for the sole purpose of assessing my/our application for credit facilities.

I/We warrant that the above details are correct and may form part of any contract between us.

Sole Traders Must print and sign email the form personally

Signed
Position
Date
Print Name