Credit Account Application

Full Name*
First Name Last Name
Account Type*
Please select your trading style.
Date of Birth*
DD slash MM slash YYYY
Company*
Company Reg. No*
Trading Name

If different from the company name.
Address*
Street Address Address Line 2 City County Postal Code
Phone Number*
Mobile Number
Fax Number
Email Address for Invoices*
Email Address*
Website
Payment Contact Name*
First Name Last Name
Have any of the principals (directors/partners/trustees or proprietor) been involved in a Liquidation/Bankruptcy/IVA/CVA/Receivership or had any CCJ’s registered against them?*
- Yes
- No
Since when have you been established?*
DD slash MM slash YYYY
Registered Office Address*
Street Address Address Line 2 City County Postal Code
Terms & Conditions*
- Yes, I agree to the terms and conditions for Logical Concrete Ltd & Land Logical Aggregates Ltd.
Signature
Signature of Applicant*
Print Name*
Position*
Date*
DD slash MM slash YYYY
Security Check

Signature