Distributor Registration - Newtech Medical Devices

Distribution Registration

Distributor Registration Form

Base Information

Company Name*

Your Email*

Billing Address*

GST Number*

D/L Number

PAN Number

Shipping Address Same As Billing Address
YesNo

Purchasing Contact

Contact Person Name

Mobile Number

Phone Number

Accounts Payable Contact

Name

Phone Number

Preferred Method of Shipping

Routing Instructions
(Will be used, unless otherwise noted on the Purchase Order.)
Weight Range

Account Number

Carrier & Contact Info

Credit Application

GST Certificate

Only PDF or JPEG Format

D/L Certificate

Only PDF or JPEG Format
Owner 1

Owner 2

Year Established

Credit Line Requested

Bank Reference

Upload Bank Ref PDF or fill in fields below:

Name

Address

Phone Number

Trade Preferences

(Required if Applying for Credit Terms - Only Vendors)

Upload Trade Ref PDF or fill in fields below:

Name 1

Address

Phone Number

Email

Name 2

Address

Phone Number

Email

Name 3

Address

Phone Number

Email

Name 4

Address

Phone Number

Email

Relative References

Name 1

Relation

Mobile Number

Name 2

Relation

Mobile Number

Name 3

Relation

Mobile Number

Name 4

Relation

Mobile Number

Name 5

Relation

Mobile Number

Friends References

Name 1

Mobile Number

Name 2

Mobile Number

Name 3

Mobile Number

I authorize Newtech Medical Devices to cross check data, I have shared about my bank representative and trade references.

I assure that details are true & correct.

I am applying for credit facility at Newtech Medical Devices, so I authorize them to cross check my credit report.

Other

Added Comments

Distribution Registration

Distributor Registration Form

Base Information

Purchasing Contact

Accounts Payable Contact

Preferred Method of Shipping

Credit Application

Bank Reference

Trade Preferences

Relative References

Friends References

Other

About Us

Useful Links

Product

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