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 (Required.)

Date

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ABN (Required.)

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Business Name (Required.)

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Type of Business (Required.)

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Doctor or Lead Technician's Name (Required.)

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Dental/Laboratory Registration Number (Required.)

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Business Owner's Name (Required.)

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Business Type (Required.)

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Website URL

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Delivery Address (Required.)

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Is your Delivery Address residential? (not operating as a business) (Required.)

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Postal Address

Please provide postal billing address if different from Delivery Address.

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Phone Number (Required.)

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Marketing Promotions Email Address

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Website Shopping Platform Email Address

An invitation to the website shopping platform will be sent to this email, to create a login. Invoices from online orders will be sent to this email.

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Contact Details: Orders (Required.)

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Contact Details: Accounts (Required.)

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Monthly Statement Email Address (Required.)

The email address would you like your Monthly Statement emailed to
Please note email copy Invoices are only sent to your nominated Portal address-this is linked via Automation in our system.
We do not provide additional email addresses to accounting firms or bookkeepers. They can be provided a Portal Log-In, to
access and manage Invoices on your behalf, at your request.
You are responsible for managing and processing your Invoices, thank you
Director/Business Partner Contact Details

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Director/Business Partner #1 (Required.)

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Director/Business Partner #1 (Required.)

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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 (Required.)

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Reference #2 (Required.)

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Reference #3 (Required.)

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 (Required.)

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Terms of Trade: read and acknowledged by
(this must be the Owner of the Business) (Required.)

T