New Media AV - Resellers Application Form

Resellers Application Form
Should you wish to become a reseller for New Media AV you should…

Please complete as much of this form as possible and where relevant.

Information such as delivery/invoice addresses are vital, as are bank details and references for credit approval.

Other details are helpful so that we know the best person to contact, but you can limit the details provided if you wish.

Resellers Application Form
Company Trading Name*:
Company Trading Address Line 1*:
Company Trading Address Line 2*:
Company Trading Address Line 3*:
Zip/Postal Code*:
Country*:
Website Address*:
Telephone*:
Fax*:
General Email*:

Company Legal Name*:
Registered Address*:
City*:
State/Region*:
Zip/Postal Code*:
Country*:
Company Registration No.*:
VAT Number*:

Directors Name*:
Job Title*:
Directors Name*:
Job Title*:

Trade Distributor Name*:
Distributor Contact Name*:
Account open for (years)*:
Account No.*:
Distributor Address Line 1*:
Distributor Address Line 2*:
Distributor Address Line 3*:
Zip/Postal Code*:
IT Trade Distributor Name*:
Distributor Contact Name*:
Account open for (years)*:
Account No.*:
Distributor Address Line 1*:
Distributor Address Line 2*:
Distributor Address Line 3*:
What Credit Limit do you wish to request?*:

Staff Contact Details
First Name*:
Last Name*:
Tel. No.*:
Mobile Phone*:
Email*:
Title/Role*: