New Customer Account Request
Account Details
Company / Trust / Org. / Govt. Department Name
*
Trading Name
*
Please verify that you are human
*
Postal Address
*
Street Address
Street Address Line 2
City
Suburb
Postal / Zip Code
Is Delivery address different from above address?
*
Yes
No
Note:
Delivery Address
*
Street Address
Street Address Line 2
City
Suburb
Postal / Zip Code
Mobile Number
Phone Number
Email
*
example@example.com
Email for Invoice (if different from above)
example@example.com
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Business Description
Business Category
*
Cafe / Bakery / Takeaway / Parlours
Convenience / Dairy
Fruit & Vege
Event & Leisure
Mobile Vending
Petrol & Convenience
Recognized Trading Group
Others
Trading Group Name
Business Details
*
Business Type
*
Registered Company
Partnership / Sole Trader
Government
Trust / Incorporated Society
Identify Government Department
*
Contact Person
Non Mandatory Option
NZ Company Registration No.
*
Registered Address same as Postal Address?
*
Yes
No
Registered Office Address
*
Street Address
Street Address Line 2
City
Suburb
Postal / Zip Code
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Director / Owner Details
Director / Owner Name
*
First Name
Last Name
Residential Address same as Postal Address?
*
Yes
No
Residential Address
*
Street Address
Street Address Line 2
City
Suburb
Postal / Zip Code
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
ID Proof
*
NZ Driving License
NZ Passport
International Passport
ID Proof Number
*
NZ Driving License Version
Next of Kin Name
*
First Name
Last Name
Relationship
*
Next of Kin address same as Requester Postal Address?
*
Yes
No
Private Address
*
Street Address
Street Address Line 2
City
Suburb
Postal / Zip Code
Phone / Mobile Number
*
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Personal Guarantee
Please read and accept below conditions
Personal Guarantee
Do you agree with Personal Guarantee ?
*
Yes
No (subject to approval)
Reason for not agreeing with Personal Guarantee terms:
Privacy Act
Do you agree with Privacy Act ?
*
Yes
No (subject to approval)
Reason for not agreeing Privacy Act
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Payment Details
Payment Type
*
Credit
Direct Debit
Merchant
Type of Credit Account requested
*
7 Days
20th of the month following
Site Code
*
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Direct Debit
Does the account you are paying from require, in terms of your bank operating authority, one signature or multiple signatures
*
One Signature
Multiple Signatures
Authorization Code
Name on Bank Account (Acceptor)
*
My bank account number
*
Suffix number must be 3 digits.
Name of my bank
*
Example: ASB, ANZ, Westpac...
Signature
*
2nd Owner / Director
First Name
Last Name
Signature (2nd)
Bank Account No Proof
*
Browse Files
Please attach Company bank account detail (either bank deposit slip or printed bank statement detail), hand written numbers are not acceptable
Cancel
of
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Change of Ownership
Is business changing ownership?
*
Yes
No
Old Business Name
Old Customer Account No
Ownership Change Date
-
Day
-
Month
Year
Date
Do you require a Freezer?
*
Yes
No
Is there a current TipTop freezer located on site?
*
Yes
No
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Freezer Terms & Conditions
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Comments / Additional info
Note:
Submit
Should be Empty: