Wholesalers

Company Name/Trading as *

Registered Company Name *

VAT Reg. No 

Company Reg. No *

First Name *

Last Name *

Phone Number *

Street Address *

Address Line 2 

Town / City *

Country and State/Region/Province *

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Postcode / ZIP *

I agree to the following *

I hereby declare that the above information is correct and that I have full legal capacity for the orders and payment thereof and hereby bind myself jointly and severally as principal debtor for the punctual payment of all sums due. I acknowledge that I have read and understood the Terms and Conditions of all business transactions between myself and MINITZA.