Sterile Single-use Products
Apply for an account

To apply for a credit account with DTR Medical please complete the form below or print it out in PDF format and post it back to us.

You must complete the boxes marked * 

Company name*:
Address*:
 
 
E-mail address*
Town / City*:
County / State:
Postcode / Zipcode*:
Country*:
 
Telephone*:
(Please provide your international dialling code)
Facsimile:
(Please provide your international dialling code)
 
Company Registration No:
Company VAT No:
 
Type of company: Plc      Ltd      Partnership      Other
 
Max credit requested:
 
Purchasing contact name:
Purchasing contact e-mail:
Purchasing contact telephone:
 
Accounts contact name:*
Accounts contact e-mail:*
Accounts contact telephone:*

Now please use the following form to give two trade references 

Trade Reference 1   Trade Reference 2
Company Name: Company Name:
Address: Address:
   
   
Town / City: Town / City:
County: County:
Postcode / Zipcode: Postcode / Zipcode:
Country: Country:
Telephone: Telephone:
Contact Name: Contact Name:
 
I/We confirm acceptance of your credit terms as set out in your Standard Terms and Conditions of Sale (available on request) and agree to pay in accordance for any goods and services supplied by DTR Medical Ltd. We understand that all accounts are strictly net and payable within 30 days from the date of invoice.
 
Applicant Name*:
Position in company*: