Account Application - Irritech Agencies International (Pty) Ltd

Irritech Account Application

Dear valued customer, please take the time to fill in this form. With the below details we will be able to provide you with the best service possible.

1General Info2Business Entity Information3Business Contact Information4Credit Application

Email*

Enter Email

Confirm Email

Key Contact PersonTitle*First Name* Last Name* Business Type*Which Irritech branch would you like to open an account with?

Which Irritech branch would you like to open an account with?*

Zambian Irritech Ltd. (Zambia Only)

Irritech Agencies International (Pty) Ltd. (South Africa and Other African Countries)

Sole ProprietorTrading Name* Proprietor – VAT Number Proprietor – Citizenship* Proprietor – ID Number* Private Company or Close CorporationCompany Name* Company Trading As* Company Registration Number / TPIN:* Company VAT Number* Director 1Director 1 – First Name* Director 1 – Surname* Director 1 – Citizenship* Director 1 – ID Number* Director 2Director 2 – First Name Director 2 – Surname Director 2 – Citizenship Director 2 – ID Number Trust Name* Trust Registration Number* Trust VAT Registration Number* Trustee 1Name* Surname* Citizenship* ID Number* Trustee 2Name Surname Citizenship ID Number Other Business TypeTrading Name* VAT Number Please enter any pertinent information about your business*Owners DetailsOwner’s Name* Owner’s Surname* Owner’s Citizenship* Owner’s ID Number*

Business Physical Address

Business Physical Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Business Postal AddressBusiness postal address different to physical address?*

Business Postal Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Contact Details (Key Contact Person)Telephone Number*Cell NumberFax NumberEmail Address 1*

Email Address 2

Contact Details (Accounts)Is Accounts contact details different from Key Contact Person?*Accounts Contact Name* Accounts Telephone Number*Accounts Email 1*

Accounts Email 2

Accounts Email 3

Credit RequestWoud you like to apply for credit from our Spares department?*Note: This only applies for items bought from our spares departments. We only offer 30 day accounts.

Credit ApplicationNameThis field is for validation purposes and should be left unchanged.

Irritech Account Application

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