CREDIT APPLICATION ACCOUNT PROFILE

Name of Company *

Main Contact Name *

Company Registration Number *

Alternative Contact Name

Invoice Address *

Ship to Address *

County

Ship to County

Country *

Ship to Country *

Postcode *

Ship to Postcode *

Business Number *

Mobile Number

Email Address (for invoicing) *

Email Address (marketing)

Are you VAT Registered? *

Yes

If YES please provide VAT No.

Account Currency (Please Tick) *

GBP

EURO

USD

HCPC Number (if applicable)

Have you had a Starkey account previously? *

Yes

Estimated monthly spend

Trade Reference 1 - Name *

Trade Reference 2 - Name *

Trade Reference 1 - Telephone Number *

Trade Reference 2 - Telephone Number *

Trade Reference 1 - Email:

Trade Reference 2 - Email:

I have read and agree to the Terms & Conditions outlined below *

Yes

Any additional information?

I have read and agree to the Data Protection Schedule outlined below. *

Yes

We'd love to share more information about our products, services and promotional offers with you. *

Yes

1. Name *

2. Name

1. Position *

2. Position

1. Date (DD/MM/YYYY) *

2. Date (DD/MM/YYYY)

I/We certify that all the information on this form is correct; and undertake to inform you of any material circumstances that change this. I/We fully understand your credit terms (see Terms & Conditions) and agree to the proper payment in consideration of extended credit.

*If based in EU and do not provide a valid VAT No. we are required to charge standard rate of VAT.

View Terms & ConditionsView Data Protection Schedule

Starkey Laboratories Ltd

William F Austin House, Bramhall Technology Park, Pepper Road, Hazel Grove, Stockport, Cheshire, SK7 5BX

Tel: +44 (0)161 483 2200
Fax: + 44 (0)161 483 9833
Email: accounts@starkey.co.uk
Website: www.starkey.co.uk | uk.starkeypro.com
Free phone: 0800 042 0000