Become a Stockist

Online Credit Application Form for Stockists
  *-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: *
Licensee Number:
Licensee Name:
Business Type:
Customer Type:
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: *
Postcode: *
Special Delivery Instructions (if any):
Postal Address
(if different from delivery address)
Postal Address 1:
Postal Address 2:
Postal Suburb:
Postal State:
Postal Postcode:

Accounts Contact Details

Accounts payable email: *
Accounts payable contact: *
Accounts telephone: *
Preferred Statement Delivery Method: *
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:
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):
Personal Guarantee Person 2 Position:

Agreement and Execution

Agreement and Execution Person 1 Name:
Agreement and Excecution Person 1 Role:
Agreement and Execution Person 2 Name:
Agreement and Execution Person 2 Role:

Personal Guarantee

Personal Guarantee Person 1 Name:
Personal Guarantee Person 1 Position:
Personal Guarantee Person 2 Name:
Personal Guarantee Person 2 Position: