Customer Account Application - Samson Fixings

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Customer
Account Application

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Account Application Form

Company Details
Company Name*
Company Registr.-No.*
Time Trading / in business
VAT NUMBER*
Postal Address*
Street Address Address Line 2 City State ZIP / Postal Code Country
Phone*
Fax
Email*
Enter Email Confirm Email
Website*
Business Info
Contact*
First Last
Business Type*
- Distributor / Fixing Specialist
- Retailer (Ironmonger etc.)
- Associated Company
- Fastening Distributer
- Distributor Merchant
- Wholesaler
- Hire Shop
- Multiple Wholesaler
- Builder’s Merchant
- DIY Superstore
- Engineer’s Merchant
Business Status*
- Ltd. Co.
- P / Ship
- Sole Trader
- Other
Backlog Orders Required?
- Yes
- No
Business Type / Other
Trade References 1
Trade References 2
Bankers
Bank*
Account*
Sort Code*
Account Number*
IBAN*
BIC/SWIFT*
Company Confirmation
Applicant Contact Info*
First Last
Position / Title*
Date*
MM slash DD slash YYYY
Confirmation on Behalf of Applicant*
- I herewith confirm that all given data is true and correct
Final consent
Privacy Note:

Samson Fixings uses your personal data for your customer account request. The retention period of your personal data is determined based on the customer account lifetime. You can at any time request the deletion of your personal data & customer account. More info: Privacy Policy
Personal Data Storage*
- I consent to Samson Fixings Ltd collecting and storing my personal data. *
Privacy Policy*
- You agree to our Privacy Policy by submitting this form. *
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