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Name of my business:__________________________________________________________

Address/registered address of my business:_________________________________________

__________________________________________________Post code: _________________

Telephone:____________________Mobile: _____________________Fax:________________

Email:_____________@____________________Website:_____________________________

Type of business: ________________________________How long established:____________

Delivery address (if different) ___________________________

___________________________________________________

Telephone:__________________________________________

Name(s) of proprietor(s)/director(s):___________________________________________

Address(es):_________________________________________________________________

___________________________________________________________________________

I enclose evidence of relevant business activity e.g. copy of advertisement, Yellow Pages entry, printed material, invoices etc.

My present suppliers are:________________________________

Signed:_______________________________________Date:__________________________