Ltd Company Application for Credit Facilities

For quick, convenient, regular ordering, without any need for a credit card, why not request a Credit Account, where you can avail of 30 day payment terms.
To apply, and have your credit account confirmed within 48 hours, please complete and submit this form:

Fields marked * are required

Company Details

Company Name *

Company Registered Address *

Address 2

Postcode
Check your EIR CODE

Tel. *

Fax

Managing Director Name *

Managing Director Email Address *

Company Reg No. *

VAT Reg No. *

Business Category *

Where did you hear about Flomax? *

Contact Details

Sales Contact *

Sales Email Address *

Sales Telephone *

Accounts Contact *

Accounts Email Address *

Accounts Telephone *

Purchasing Contact *

Purchasing Email Address *

Trade References

Please provide details of two companies that you have dealt with recently.

Reference 1

Company Name *

Address Line 1 *

Address Line 2

Postcode
Check your EIR CODE

First Name *

Last Name *

Email *

Telephone *

Reference 2

Company Name *

Address Line 1 *

Address Line 2

Postcode
Check your EIR CODE

First Name *

Last Name *

Email *

Telephone *

Bank Details

Bank Name *

Bank Address *

Sortcode *

Account No. *

Agreement

Please insert your name so we can generate your Electronic Signature *

Tick here if you are exempt from VAT. (And please do not forget to send your VAT exempt form to sales@flomax.ie in order to confirm that you are exempt from VAT).

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I Accept FloMAX Terms & Conditions and Privacy Policy.

Call us on 0818 201 444

Call us on 0818 201 444
International: +353 1 4568111

Ltd Company Application for Credit Facilities

Reference 1

Reference 2

Call us on 0818 201 444

Call us on 0818 201 444International: +353 1 4568111

Ltd Company Application for Credit Facilities

Reference 1

Reference 2

Call us on 0818 201 444
International: +353 1 4568111