HEALTH

REVOLUTION PTY LIMITED, ABN: 42 155 684 843

APPLICATION FOR COMMERCIAL CREDIT I/we hereby apply for credit and submit the following confidential information for this purpose only. NAME AND ADDRESS OF BUSINESS Trading Name Trading Address Postcode Postal Address Postcode Telephone Facsimile Date Commenced Email Trading Number of employees Contact Name for Account Queries Contact Phone Number PARTICULARS OF COMPANY/SOLE TRADER/PARTNERSHIP/CO-OPERATIVE (Strike out that which does not apply) COMPANY/SOLE TRADER/ PARTNERSHIP/CO-OPERATIVE Full Name of Company/ Sole Trader/ Partnership/Co-operative applying for credit (Applicant) If a company or co-operative: Registered Office If company ABN No: Date of Incorporation:

Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029

Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

 APPLICATION FOR COMMERCIAL CREDIT

If co-operative Registration No: AUTHORISED PURCHASING OFFICER Name Title Contact phone number TRADE REFERENCE 1 Supplier Name Address Telephone TRADE REFERENCE 2 Supplier Name Address Telephone

Date of Registration:

Terms: Payment CBD (Cash Before Delivery) for the 1st order. The 1st instalment will be paid via credit card or eft the day the order is placed. Subsequent purchases are due for payment 30 Days from the Invoice date after credit is approved. Credit facilities may be withdrawn or varied by Health Revolution if these terms are ignored. Health Revolution reserves the right to charge interest at the rate of 1.5% per month on overdue monies and the purchaser agrees to reimburse Health Revolution for any legal expenses incurred in the recovery or attempted recovery of such monies. Cheques and payments shall be made payable to the company. Payments by cheque shall not be deemed made until the cheques have been cleared. Where you are in default of Health Revolution Terms and Conditions, Health Revolution reserves all of its rights under the PPSA, including the right to recover goods and money secured. Words and expressions which have a defined meaning in the PPSA have the same meaning when used in Health Revolution Terms and Conditions.
Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029 Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

 APPLICATION FOR COMMERCIAL CREDIT

CREDIT CARD AUTHORISATION - please tick if applicable for 1st payment ACCOUNT DETAILS Account Name _____________________________________________________________________ Name one card _____________________________________________________________________ Credit Card Type____________________________________________________________________ Credit Card Number _________________________________________________________________ Expiry Date_________________________________________________________________________
Visa and Master Cards attract a 1% surcharge. Amex and Diners 2.7%

EFT BANK TRANSFERS please tick if applicable for 1st payment. Health Revolution Pty Ltd - ABN 42 155 684 843 Bank Account: BSB # 012281 Account # 530459388 The Applicant acknowledges that he/she has received a copy of the Health Revolution Pty Limited terms and conditions prior to him/her signing this application. The person(s) signing this application warrants that he/she has read and fully understands the nature and effect of the terms and conditions, and has the authority to sign on behalf of the Applicant and the information provided is true and correct in every detail. Signed Date
Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029 Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au

 APPLICATION FOR COMMERCIAL CREDIT

Debtor Code Trade References Checked : 1 2 3 Authorisation to open this account has been Approved credit limit Signed ___________________________________

HEALTH REVOLUTION PTY LTD Office use only

GRANTED $2,000.00 Date __________

DECLINED

Health Revolution Pty Limited, ABN: 42 155 684 843 Suite 2/19 Salisbury Road, Rose Bay. Sydney, NSW 2029

Telephone +61 2 93621953 Fax +61 2 8246 6391 orders@healthrevolution.net.au