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Media Village Questionnaire
Customer Account Details
Company Info
Name of Company
Type
A limited company
A partnership
A sole trader
Other
Please specify 'Other'
Company Reg No
Vat No
Trading Address
Street Address
County / State / Region
ZIP / Postal Code
Years at this address
Months
Please supply previous address
Street Address
County / State / Region
ZIP / Postal Code
Telephone
Fax
Email
How many years have you been trading
Monthly Expenditure
Are you paying upfront or pro forma?
In Advance/Cash on Collection
Proforma/With a view for a credit account
Amount of credit applied for
Accounts Contact
Purchase Order Number Required
Yes
No
Sole Trader Details
Name
Phone
Fax
Email
Address
Street Address
County / State / Region
ZIP / Postal Code
Partnership Details
Person 1
Name
Phone
Fax
Email
Address
Street Address
County / State / Region
ZIP / Postal Code
Person 2
Name
Phone
Fax
Email
Address
Street Address
County / State / Region
ZIP / Postal Code
County Court Judgments (CCJs)
Have you had any county/high court judgements made against the applicant in the last six years?
Yes
No
Please detail
Signature
Name
Position
Consent
(Required)
I, the undersigned, confirm that the information given is true to the best of my knowledge. We hereby apply for credit from Academy Print and Design (UK) Ltd trading as "Media Village" and agree to the Terms and Conditions as stated overleaf. Trading terms 30 days from the date of invoice. The first order placed is Pro Forma.
