Credit Account Application Form - Reitzer Healthcare (Pty) Ltd

Credit Account Application

Company Name & Contact Details:

Business Type:(required)

CC (Pty) Ltd Sole Proprietor / Partnership

Registered Company Name: (as registered on CIPC)

Company Trading Name: (if different to Registered Company Name)

Business Registration Number:

Nature of Business:

Year that Business was established:

Period under current ownership:

VAT Number:

Website Address or Facebook Page URL:

Physical Address / Business Address

Complex Name / Business Park Name

Unit Number

Street Number(required)

Street Name(required)

Suburb Name(required)

Province(required)

Postal Code(required)

Postal Address (If not the same as the above)

Address Line 1

Address Line 2

Province

Postal Code

Delivery Address (if different from Physical / Business Address)

Complex Name / Business Park Name

Unit Number

Street Number

Street Name

Suburb Name

Province

Postal Code

Contact Details

Name of Person Responsible for Account:(required)

Email Address:(required)

Name of Person Responsible for Orders:(required)

Email Address:(required)

Company Contact Number:

Type of Company(required)

Retail Pharmacy (Independent) Pharmacy Buying Group Other

If "Other" selected above, please state the Type of Company below:

Details of Directors / Owners / Members

1. First Names & Surname(required)

Physical Home Address:(required)

RSA ID / Passport Number:(required)

Cell Phone Number:(required)

Email Address:(required)

Work Phone Number:

2. First Names & Surname

Physical Home Address:

RSA ID / Passport Number:

Cell Phone Number:

Email Address:

Work Phone Number:

3. First Names & Surname

Physical Home Address:

RSA ID / Passport Number:

Cell Phone Number:

Email Address:

Work Phone Number:

Domicillium citandi et executandi: (Physical address for service of all legal documentation & correspondence)

Complex Name / Business Park Name

Unit Number

Street Number(required)

Street Name(required)

Suburb Name(required)

Province(required)

Postal Code(required)

Bank Details:

Bank Name:(required)

Branch Name:

Branch Code:(required)

Bank Account Name:(required)

Bank Account Number:(required)

Credit Limit Required:(required)

Does the total assets of the business or the annual turnover exceed R 2 000 000.00?(required)

Yes No

Trade References:

Please supply 3 references, ONLY one of which may be a Pharmaceutical Wholesaler, if a Non-Pharmaceutical Company or Pharmacy, 3 suppliers references where purchases are more than R10 000 per month:

Trade Reference 1:

1. Company Name:(required)

Average Monthly Purchases:(required)

Tel. Number of Reference:(required)

Address of Reference:

Trade Reference 2:

2. Company Name:(required)

Average Monthly Purchases:(required)

Tel. Number of Reference:(required)

Address of Reference:

Trade Reference 3:

3. Company Name:(required)

Average Monthly Purchases:(required)

Tel. Number of Reference:(required)

Address of Reference:

Premises:

Are the premises owned by the Shareholders / Directors?(required)

Yes No

If no, please provide the following information:

Name of Landlord:

Landlord Contact Number:

Auditors Details:

Auditors Name:(required)

Auditors Contact Number:(required)

Please tick where applicable below:

Has the entity issued or signed any guarantees in favour of other creditors?(required)

Yes No

If yes, please provide details:

Have the Directors / Members issued or signed any guarantees in favour of other creditors?(required)

Yes No

If yes, please provide details:

Have the principals ever been directors/members of a business that was liquidated or underwent business rescue?(required)

Yes No

If yes, please provide details:

Has the Customer's debtor book, or any specific debtor been ceded?(required)

Yes No

If yes, please provide details:

Please email the following documents to debtors@reitzer.co.za along with the submission of this application:

Certificate of Incorporation
VAT Registration Certificate
Copy of Director/s Identification
Proof of Business Address (Utility Bill / Lease Agreement – not older than 3 months)
B-BBEE Certificate
Signed Suretyship (Attached to the email)

Terms & Conditions:

I/We warrant that the information contained herein is true and correct in every respect.
I/We undertake to notify the Supplier in writing immediately of any change in this information.
I/We am duly authorized to sign this application. I/We acknowledge that I/We have read and understood the terms and conditions attached hereto and agree that such terms and conditions shall be binding upon me/us/the company/close Corporation in respect of all transactions entered into between myself/ourselves and the Supplier.
I/We agreed that the Supplier may use the services and records of a registered credit bureau and other suppliers for information required in the initial and future assessment of credit facilities.
I/We agree that the Supplier may disclose information regarding the applicant’s credit worthiness and conduct of the account to any registered credit bureau.
I/We agreed to an ITC check in order to validate credit worthiness. If the Customer does not agree to an ITC check, the Supplier will be unable to open an account and will revert to a COD Customer / any form of account being opened

Please Note:

ONLY EFT payments accepted.
Once your 30-Day Account application has been credit vetted and approved, you will receive an email with your account details, our Delivery Charges Document (Please see minimum order value for free delivery) and the Reitzer Healthcare Price List. In the case where more information is required our staff will contact you.
The minimum order value means the total value of the order after discount (if any) and excluding VAT.
Deliveries take place within 5-7 days provided we have the relevant stock on hand.
Accounts run from the 26th to the 25th of the following month. Payments must be received by the 25th of the month. Should the 25th fall on a Saturday, Sunday or Public Holiday then payment must be made by the preceding Business Day.
The Supplier shall at its discretion give a settlement discount equivalent to 2.5% on accounts paid within the 30 (thirty) day period and by the dates referred to above.

By ticking this box I/we agree to the terms and conditions.(required)

Click on the link below to read our Terms & Conditions.

Credit Application Terms & Conditions Download

* Means Required

I/We acknowledge that by virtue of this application submission that I/we have read and agreed to bind itself, its shareholders, directors, employees, agents to strict compliance with all the terms and conditions of trading.