Ivoclar Vivadent Ltd - GST No. 010-105-293
Application for Customer Credit Account
12 Omega Street, Rosedale, Auckland, 0632
Customer Services Telephone: 0508 486 252
Accounts Telephone: 0508 486 255

Please ensure all parts of this form are fully completed

IMPORTANT: If there are any concerns regarding this application, or any sections that require further clarification, we recommend that you seek independent legal advice.

PART 1: CREDIT APPLICATION

1. The Applicant

Legal full name of entity *

Trading Name (if different from legal name)

Are you GST Registered? *

NOYES

GST No. *

Date Business Commenced

Is this new application related to a change of ownership or existing account? *

NOYES

Account No: *

Account Type *

Other Account *Please describe what you do?

Name of Corporate Organisation *

Dental Council Registration number (if applicable)

If friend recommendation, please provide contact name and email

If Other, please specify: *

Details of Student

Student Name *

Passport Number *

Copy of Passport *

Browse

Driver Licence Number *

Copy of Drivers Licence *

Browse

Student ID Number *

Copy of Student ID *

Browse

Details of Registered Dentists

Dentist Name *

Dentist Name

Technicians Details

Technician Name *

Technician Name

Details of Prosthetists

Prosthetist Name *

2. Contact Details

Principal Business Address *

Suburb

City / Region *

Postcode *

Business Owner's Name *

Business Owners Occupation *

Business Owner's Email Address *

Business Telephone Number *

Account Contact Name (for payment enquiries ) *

Accounts Email Address (we will send invoices/statements to this address) *

Accounts Telephone Number *

Ordering Contacts Name (for order enquiries)

Ordering Contacts Email Address

Ordering Contacts Telephone Number *

Delivery address (if different to Principal Business Address as above)

Delivery Address *

3. Business Profile

If other, please explain *

Anticipated Spend (Monthly) *

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3.1. Sole Trader Details / Partnership

Full Name of Proprietor *

Residential Address *

Full Name of Proprietor

Residential Address

3.1. Company Directors

Name of Director *

Residential Address *

Name of Director

Residential Address

Name of Director

Residential Address

3.1. Trust Details

Name of Trust

Type of Trust *

Family / DiscretionaryUnitOther (enter details below)

Other *

If a unit trust, provide details of all unitholders

Name *

Address *

Name

Address

Name

Address

4. Trade / Business References

Not Applicable

Please provide three trade or business references. These must be provided by current key suppliers that are providers of commercial credit.

Reference One

Business Name

Contact Name

Address

Email

Telephone

Reference Two

Business Name

Contact Name

Address

Email

Telephone

Reference Three

Business Name

Contact Name

Address

Email

Telephone

5. Terms of Credit

Credit will not be provided until Ivoclar Vivadent Ltd accepts this application and has provided written confirmation to the Applicant.

If Ivoclar Vivadent Ltd accepts this application, the provision of goods and services and credit facilities to the Applicant are subject to the Terms and Conditions of Trade.

I have read and agree to the terms and conditions. *

6. Execution

By signing this credit application, the Applicant:

Represents & warrants that this information is true and correct to the best of their knowledge
Gives consent to the trade and personal references being contacted to gain trading information
Acknowledges having been provided with Terms and Conditions of Trade of Ivoclar Vivadent, and having read and understood them
Acknowledges that they have been advised to seek legal and financial advice prior to signing this application
Accepts the Terms and Conditions of Trade of the Company as displayed on its website ( www.ivoclar.com) and agrees that these Terms and Conditions of Trade apply to the provision of goods and services to it by Ivoclar Vivadent Ltd

If the applicant is a company or corporate trustee this application must be signed by a director or trustee of the named entity

Authorised Signatory One

Sign Here *

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Date *

Full Name *

Position or Business Title *

Other, please indicate *

Signing in the Capacity as: (for the named legal entity) *

Authorised Signatory Two (if required)

Sign Here

Draw signature|Type signatureClear

Date

Full Name

Position or Business Title

Other, please indicate

Signing in the Capacity as: (for the named legal entity)

Authorised Signatory Three (if required)

Sign Here

Draw signature|Type signatureClear

Date

Full Name

Position or Business Title

Other, please indicate

Signing in the Capacity as: (for the named legal entity)

Part 2: Deed of Guarantee and Indemnity

TO: IVOCLAR VIVADENT LTD (GST No. 010-105-293) of 12 Omega Street, Rosedale, Auckland, 0632

In consideration of Ivoclar Vivadent Ltd ("Ivoclar Vivadent") providing or continuing to provide goods & services, credit or grant an indulgence outside Ivoclar Vivadent Ltd agreed credit terms to the customer as hereby named below:

Name of Customer

ACN or ABN of Customer

Address

The Guarantor hereby:

1. Agrees to guarantee to Ivoclar Vivadent the due and punctual payment of all money presently owing and any money that may become owing by the Customer, in respect of the cost of goods or services supplied by Ivoclar Vivadent to the Customer and any other sums payable by the Customer to Ivoclar Vivadent pursuant to Ivoclar Vivadent Terms and Conditions of Trade ( guaranteed money);

2. Agrees as a separate severable and additional covenant and obligation to indemnify and keep indemnified Ivoclar Vivadent from and against all losses, costs, charges and expenses whatsoever (including all legal costs) that Ivoclar Vivadent may suffer or incur in relation to the supply of goods or services to the Customer;

3. Covenants, acknowledges and agrees as follows:

(a) The guarantee given in clause one is a continuing guarantee, the indemnity given in clause two is a continuing indemnity and neither this Deed nor the guarantee nor the indemnity will be discharged in any way or be considered or deemed to be discharged in any way by any payment to Ivoclar Vivadent, other than the full payment to and acceptance by Ivoclar Vivadent of the whole of the guaranteed money;
(b) Notwithstanding that as between the Guarantor and the Customer the position of the Guarantor is that of surety only. Nevertheless as between the Guarantor and Ivoclar Vivadent, the Guarantor is liable as a principal and as a primary debtor for the payment of the guaranteed money;
(c) This Deed is valid and enforceable against the Guarantor and the liability hereunder of the Guarantor continues and may be enforced by Ivoclar Vivadent notwithstanding:
1. That no steps or proceedings have been taken against the Customer;
2. Any indulgence or extension of time granted by Ivoclar Vivadent to the Customer;
3. The death or bankruptcy or winding up of the Customer;
4. That payment of the guaranteed money by the Customer cannot be legally enforced against the Customer;
(d) Ivoclar Vivadent taking or failing to take, or enforcing or failing to enforce, or holding any other security for the Customer's debt, or varying or surrendering any such security shall not exonerate or discharge the Guarantor or otherwise prejudice or affect the liability of the Guarantor;
(e) The Guarantor must not compete with Ivoclar Vivadent for any dividend or distribution in the event of the Customer being declared bankrupt, going into liquidation or being wound up or entering any deed or scheme of arrangement or assignment or composition in respect of its affairs or its assets and liabilities;

4. Where the Guarantor consists of more than one person, this guarantee is enforceable against all persons signing as Guarantor jointly and severally

5. The Guarantor hereby acknowledges having given its consent to Ivoclar Vivadent to:

(a) Disclose credit information about the Guarantor to a credit reporting body; and

(b) Obtain credit eligibility information about the Guarantor from a credit reporting body; and

(c) Use credit eligibility information about the Guarantor; and

(d) Disclose credit eligibility information about the Guarantor, or the purposes of Ivoclar Vivadent :

(e) Assessing whether to accept the Guarantor as a guarantor for credit that has been provided to or may be applied for by the Customer; and

(f) Collecting overdue payments; and

(g) Reporting on payment defaults and personal bankruptcy and insolvency issues

6. The term "Ivoclar Vivadent" includes its successors and assigns and the terms "Customer" and "Guarantor" include their respective executors, administrators and successors.

Guarantor Signatory One

Sign Here (Guarantor One)

Draw signature|Type signatureClear

Date

Full Name (Guarantor One)

Residential Address (Guarantor 1)

Sign Here (Witness)

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Name & Address of Witness

Guarantor Signatory Two

Sign Here (Guarantor Two)

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Date

Full Name (Guarantor Two)

Residential Address (Guarantor Two)

Sign Here (Witness)

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Name & Address of Witness

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