Application for Credit Account

To apply for a credit account with Your Health NZ, please complete and submit the form below. Once received, our team will review your application and be in touch with you shortly.

Trading Name(Required)

Company Name(Required)

Company Registration Number

NZ Business Number

Postal Address

Postal Address(Required)

Street Address Town / City ZIP / Postal Code

Delivery Address

Same as postal address

Delivery Address

Street Address Town / City ZIP / Postal Code

Phone(Required)

Delivery Address

Invoices/Statements(Required)

General(Required)

H+S or HR Manager(Required)

Would you like to sign up to our mailing list?

Note: All invoices emailed daily and statements EOM.

Trade References

Name(Required)

Position(Required)

Company(Required)

Contact Details(Required)

Declaration(Required)

We agree to pay all debts when due

We acknowledge that credit may be withdrawn at any time without prior notice in accordance with Your Health NZ terms of trade

We agree that any change in respect of ownership, legal entity or address be notified within 7 days.

We acknowledge that we have read the Your Health NZ standard terms of trade and acknowledge that these conditions may be changed unilaterally from time to time.

We authorise Your Health NZ to access credit information from 3rd parties with respect to their dealings with us to access any information held by any credit agency about us.

I certify that I am authorised to sign this credit application form on behalf of the business named and the information given is true and correct to the best of my knowledge.

My Name is:(Required)

My Role is:(Required)

My contact details are:(Required)