Novamoda Retailers

Private and Confidential

I/we, the author, in my/our capacity as the Duly Authorised representative of the applicant,
hereby apply for a credit facility from Novamoda (Pty) Ltd. The following information is submitted
as the basis for your consideration of my/our application :

Company Details :

Applicants registered name:
Trading Name :
Nature of Business :
Corporate registration number :
Date Commenced Business :
VAT Reg. No. :

Tick the appropriate block	Company
	Close Corporation
	Partnership
	Sole Proprietorship

If a subsidiary of a group, state name of holding company :

Auditor details	Name
	Telephone Number

Addresses	Business
	Postal
	Registered office

Contact details	Telephone number
	Telefax number
	Cellphone number
	Contact Person

Trade References

Company name

Telephone number

Purchases p/m

Director/Members/Partners/Prior :

Full name	ID number	Residential address	Cellphone

Are your premises	Owned
	Rented

Landlords details	Name
	Telephone number

Bank Details	Bank
	Branch
	Account number

Credit facility required

Are you interested in using our e-commerce internet system ?

Acknowledgement

I / we hereby certify that the information contained in this document is true and correct in every respect. I/we undertake to notify the supplier in writing of any change to the details above. I/we agree that the information given could be verified by the Credit Bureau.

I / we acknowledge that credit facilities granted by the supplier to us shall be at the sole discretion of the supplier regarding nature, duration and extent of the facilities.

I / we hereby accept and undertake irrevocably to be bound by the Terms and Conditions of contract as set out in the pages linked to this application.
I / we acknowledge having read and understood the Terms and Conditions and agree on behalf of the applicant to the Terms and Conditions, relating to the purchases and goods from Novamoda (Pty) Ltd., and further agree to the Terms and Conditions being applicable to any further facility which may be made available from time to time by Novamoda (Pty) Ltd.