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Ingham Account Application Form

Use this online application form to apply for an account.

1Start the Application

2Business Information

3Account Information

4Terms and Conditions

Apply for a Credit Account.

Please note, this application form is only for businesses with delivery addresses in New Zealand.

How would you like to apply? *

As an individual
As a business

Please select a Dealership *

Business Information

Business Status *

Limited Company
Sole Proprietor
Partnership
Individual
Trust / Society / Charity

Company Name *

Registered Trading Name *

GST Number *

Nature of Business *

Number of Employees *

Registration Number *

Date Established *

Accountant *

Smart Loyalty / Smart Trade Number (if applicable)

Business Phone Number

Invoice and Statement email address

Physical Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Postal Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Ownership

(please insert Owner (s) / Directors (s) / Partners Name (s) in full)

1st Director / Proprietor’s Full Name

Title *

Full Name *

First

Middle

Last

Date of Birth *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

2nd Director / Proprietor’s Full Name

Title

Full Name

First

Middle

Last

Date of Birth

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please provide Trading References

Trading Reference I *

Trading Reference I

Phone I *

Phone Number Trading Reference I

Trading Reference II

Trading Reference II

Phone II

Phone Number Trading Reference II

Trading Reference III

Trading Reference III

Phone III

Phone Number Trading Reference III

Credit Limit Requested *

Account Contact Information

Title *

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone Number *

Alternative Phone Number

Date of Birth *

Drivers Licence Number *

Drivers Licence Version *

Vehicle Registration Number *

Credit Limited requested *

Alternative Contact

(please enter an additional contact person)

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Terms and Conditions

I/We hereby apply to open a credit account with Ingham Group Services Limited (Ingham). I/We have read and fully understand Ingham’s Terms and Conditions of Trade and agree to abide by them. All electronic communications regarding the set up and use of a credit account are subject to the provisions of the Electronic Transactions Act 2002.

Accept Terms and Conditions*

Accept Terms and Conditions*

Please click here to view our Terms and Conditions.

Signature *

Authorised Signatory

Name Authorised Signatory *

Name Authorised Signatory

Position Held *

Position Authorised Signatory

Date of Application *

Date of Application

_____________________________________

For office use only

For office use only

ID Verified
Checks Completed
Application Approved
Application Declined

Layout

A/C No

A/C No

Code

Code

Approved / Declined by

Authorised by

Credit Limit

Credit Limit

Date

Date

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