City Dental Supplies New 30-Day Account Request Form

Please fill in the below form to open a purchasing account with City Dental Supplies. 
We will reach out within 2 business days to confirm the account has been opened, or to request further information if required.

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* Date of Form Completion

Date

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* ABN

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* Business Name

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* Type of Business

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* Doctor or Lead Technician's Name

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* Dental/Laboratory Registration Number

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* Business Owner's Name

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* Business Type

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* Website URL

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* Delivery Address

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* Postal Address

Please provide postal billing address if different from Delivery Address.

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* Phone Number

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* Marketing Promotions Email Address

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* Shopping Portal Email Address

An invitation to the portal will be sent to this email, to create a login.

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* Contact Details: Orders

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* Contact Details: Accounts

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* Monthly Statement Email Address

The email address would you like your Monthly Statement emailed to
Director/Business Partner Contact Details

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* Director/Business Partner #1

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* Director/Business Partner #1

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* Director/Business Partner #2

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* Director/Business Partner #2

Credit Reference
Please provide contact information for credit references. 
The referee may be contacted.

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* Reference #1

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* Reference #2

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* Reference #3

Please review our Terms of Trade to complete your application:
City Dental Supplies Terms of Trade

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* I hereby certify that I have read and acknowledge the Terms of Trade attached to this Account Application

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* Terms of Trade: read and acknowledged by

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