Contact Us

To apply for credit, simply complete the form below or download the form in PDF format (417kb), complete it and post it back to us.

Areas marked with * indicates fields that are required.

Company name*:
Address*:
Town / City*:
County / State:
Postcode / Zipcode*:
Country*:
Telephone*:	(Please provide your international dialling code)
Facsimile:	(Please provide your international dialling code)
Company Registration No:
Company VAT No:
Type of company:	Plc      Ltd      Partnership      Other
Max credit requested:
Purchasing contact name:
Purchasing contact e-mail:
Purchasing contact telephone:
Accounts contact name:
Accounts contact e-mail:
Accounts contact telephone:

Trade Reference 1		Trade Reference 2
Company Name:		Company Name:
Address:		Address:
Town / City:		Town / City:
County:		County:
Postcode / Zipcode:		Postcode / Zipcode:
Country:		Country:
Telephone:		Telephone:
Contact Name:		Contact Name:

	By checking this box, I/We note your credit terms as set out in your Standard Terms and Conditions of Sale (available on request) and agree to pay in accordance for any goods/services supplied by you. All accounts are strictly net and payable within 30 days from date of invoice.

Applicant Name*:
Position in company*:

For further information or to discuss your credit application please contact accounts@shieldmedicare.com or phone 01252 717616.