Become a Stockist
Online Credit Application Form for Stockists
7D30645BA74408E8D0FF2CA7F8686540
*
-Required
Interested in becoming a Fourth Wave Wine stockist? Please complete the below application form and a representative in your area will be in touch soon.
Trading/Business Name (
The name that your company trades as
):
*
Registered Company Name:
ABN/ACN:
*
Banner Group Name
(
If applicable
):
Legal Structure:
--Select--
Sole Trader
Partnership
Company
Trust
*
Licensee Number:
Licensee Name:
Business Type:
--Select--
Retail
On Premise
etailer
Customer Type:
--Select--
Retail
On Premise
etailer
Distributor
Wholesaler
Email Address(
A general email address that we can contact you on
):
*
Website(
Enter the URL of your website if available
):
FWW Sales Representative(
If known
):
Address Details
Delivery Address
(Your preferred business delivery address)
Address 1:
Address 2:
Suburb:
*
State:
--Select--
NSW
ACT
NT
QLD
SA
TAS
VIC
WA
*
Postcode:
*
Special Delivery Instructions (if any):
Postal Address
(if different from delivery address)
Postal Address 1:
Postal Address 2:
Postal Suburb:
Postal State:
--Select--
ACT
WA
TAS
QLD
NT
SA
NSW
Postal Postcode:
Accounts Contact Details
Accounts payable email:
*
Accounts payable contact:
*
Accounts telephone:
*
Preferred Statement Delivery Method:
--Select--
Post
Fax
Email
*
Preferred Statement Email Address:
Payment Details
Payment Terms
All invoices are due for payemnt on 15th of the following month. Please provide your credit card details below if you would like us to co-ordinate the timing of your payments to ensure you receive our 2.5% on-time payment discount when paying on time. You will recieve a payment receipt from our office at the time of payment. Alternatively, call 1300 778 047 to provide your credit card details.
Card Type:
--Select--
Master Card
VISA
American Express
Credit Card Name:
Credit Card Number:
Expiry Date:
CCV:
Trade References
A minimum of 3 trade references are required to open an account with Fourth Wave Wine. NB: COD Account - no trade references required)
Trade Reference 1
Company Name 1:
Address 2:
Contact Person 1:
Phone 1:
Email 1:
Trade Reference 2
Company Name 2:
Contact Person 2:
Phone 2:
Email 2:
Trade Reference 3
Company Name 3:
Contact Person 3:
Phone 3:
Email 3:
How did you hear about Fourth Wave Wine? (Referral Program Incentive):
--Select--
Google or other search
Word of mouth
Advertisement
Article or blog post
Social Media
Personal Guarantee Person 2 Position:
Agreement and Execution
Agreement and Execution Person 1 Name:
Agreement and Excecution Person 1 Role:
--Select--
Director
Partner
Sole Trader
AUthorised Officer
Agreement and Execution Person 2 Name:
Agreement and Execution Person 2 Role:
--Select--
Director
Partner
Sole Trader
Authorised Officer
Personal Guarantee
Personal Guarantee Person 1 Name:
Personal Guarantee Person 1 Position:
Personal Guarantee Person 2 Name:
Personal Guarantee Person 2 Position: