Credit Account Application

Fields marked * must be completed

Please ensure all fields marked with * are complete, and you have entered the validation code correctly.

Organisation Details

Full Company Name*

Trading Name (if different)*

Legal Title*

Company Registration No.*

VAT No.*

Title*

First Name*

Email Address*

Job Title*

Type of Business

Number of Employees

Number of years in business*

Is application for a one-off purchase

Have you bought from us before

Your monthly stationery spend

Would we be your Sole Supplier

Credit limit requested

Organisation Details Cont.

Address Line 1*

Address Line 2

Town/City*

Region*

Postcode*

Country

Telephone*

Fax

Accounts Tel No. (if different)

Accounts Contact Name

I prefer to receive invoices by?

Join Mailing List*

Delivery Address

Address Line 1*

Address Line 2

Town/City*

Region*

Postcode*

Invoice Address (If Different)

Address Line 1

Address Line 2

Town/City

Region

Postcode

Commercial 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. These companies should not be connected with your company in any way, other than a normal trading relationship.

Reference 1

Name*

Address Line 1*

Address Line 2*

Town/City*

Region*

Postcode*

Telephone*

Fax*

Reference 2

Name*

Address Line 1*

Address Line 2*

Town/City*

Region*

Postcode*

Telephone*

Fax*

How did you hear about Eximedia?

Any additional comments

Anti-Spam/Form Validation

Please copy the characters you see below and submit the form to us for review. We will be in touch shortly to discuss your application.