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BioCeuticals® Practitioner Account Application

If you already hold an account with BioCeuticals® and would like access to our practitioner section please contact our Customer Service team on 1300 650 455 or email cs@fit.net.au
Required
Application For:
 
Account Type:
 
Account Details:
Required
Account Name:  
Trading Name:  
Postal Address:  
Postal Suburb  
Postal State:  
Postal Country:  
Postal PostCode/ZIP:   
Delivery Address:  
Delivery Suburb  
Delivery State:  
Delivery Country:  
PostCode/ZIP:   
Telephone:   
Facsimile:
Email:   
Password:  
Confirm Password:  
Business Details:
Required
 
ACN/ABN  
Years business has traded:   
If Company and/or Partnership please list full name and address of Proprietors/ Directors/ Partners:
Proprietor(s) / Directors Name:
 
Given Name(s):  
Surname:  
Telephone(Work):   
Telephone(Home):  
Telephone(Mobile):  
Fax:  
Email:   
Address:  
Suburb  
State:  
Country:  
PostCode/ZIP:   
Bankers:  
Branch:  
Premises:
 
Accounts Payable Contact:  
Estimated Monthly Purchase:   
Credit Limit: (nominate an amount below - optional)
Amount: (In AUD $)  
Trade References:
Required for 30day Account Only
1. Business Name:
1. Telephone:  
1. Facsimile:  
2. Business Name:
2. Telephone:  
2. Facsimile:  
3. Business Name:
3. Telephone:  
3. Facsimile:  
Applicant Details:
Required
Practitioner Name:
 
Given Name(s):  
Surname:  
Qualification:  
Association Name:  
Association No.:  
Patient Ordering System Setup
Optional
PB Code 1: Your Account Number- Markup: %
PB Code 2: Your Account Number- Markup: %
PB Code 3: Your Account Number- Markup: %
PB Code 4: Your Account Number- Markup: %
PB Code 5: Your Account Number- Markup: %
Terms and Conditions

I have read and agreed to the Terms and Conditions of sale (HERE), and that:

I/we hereby authorise BioCeuticals® to make any enquiries or disclose any information concerning my/our credit worthiness to any person or source as considered appropriate by BioCeuticals® (Section 18L (4) Privacy Act 1988). If granted Credit, I/we agree to pay all invoices within 30 days of the end of month. It is agreed that I/we will pay 1% interest per month (from the invoice specified 'DATE DUE FOR PAYMENT') which is 12% per annum on all past due balances. My/our financial situation is satisfactory and I/we can meet all financial obligations. There are no lawsuits against me/us at this present time. If I/we default on any payment of any outstanding valid invoices I/we agree to pay attorney and/or collection expenses.

I/we make an application for an account for the purpose of obtaining merchandise from BioCeuticals®