PRO Dental Trade Account Registration Form

Your company details

Company name *

Company website *

Social media profiles

General Dental Council (GDC) number *

Vat number *

Trading address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Registered address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Company registration number (if applicable)

Invoice address (if different to trading address)

Delivery address (if different to trading address)

Main telephone number *

Main email *

Accounts contact name *

First

Last

Full name(s) and address(es) of proprietors or partners (if not a limited company)

Customer credit application

Do you require credit? *

Yes
No

All first orders are pro-former.

Trade references

Please supply below details of two companies that we can approach to obtain credit references. These should be current suppliers who extend credit to at least the same amount as your current application. Please note that without two satisfactory trade references the application cannot be processed.

Trade reference 1 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Trade reference 2 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Total amount of credit required: *

Acceptance of terms

We hereby acknowledge receipt of your standard terms and conditions of sale and agree to be bound by them. We are aware that your normal payment terms (Credit Accounts) are strictly 30 days end of month following invoice and that any goods supplied remain the property of Clinical Health Technologies Ltd until all goods supplied have been paid for.

I accept the terms

Name *

First

Last

Date *

Basket

Would you like to become a stockist of Clinisept+ Dental? We offer trade accounts for dentists and dental practices. Register for a Trade Account today.

Your company details

Customer credit application

All first orders are pro-former.

Trade references

Acceptance of terms

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