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Fields marked with an * are compulsory
Please complete all details on the form below and click on "Send Form" or print out the form and fax back to us on Free Fax 1800 626 739 (1800 MANREX) or Fax (02) 9563 4955.
* Please click on system being applied for:
Community Webster-pak
        (incl. Community software)
Unit Dose 7 Webstersystem
Multi Dose Webster-pak
        (incl. Professional software)
Budget Webster-pak (No Software)
Multi Dose Webster-pak
        (incl. Professional Plus software)
Cold Seal Webster-pak

New Accounts: Complete the application form below. Send it with the Trade Mark registration form to Manrex Pty Ltd – Webstercare at the address below.

Freight Charges: Freight is charged for orders dispatched at the price charged to Manrex by the freight company. If at any time an alternative company is preferred, please advise. Manrex has negotiated substantial discounts on freight rates.

Payment Terms: All accounts are payable NET 30 days from the end of the month during which purchases were made. Accounts not paid by the due date will be surcharged 2.5% per month for the outstanding amount.

* Full Trading Name:   
Business Address:   
  Suburb: State: Postcode:
 
Postal Address:   
  Suburb: State: Postcode:
  * Phone: Fax:  
   
* Email:
Proprietor (s)
Name (s):
 
  
  
Proprietors Address:   
  Suburb: State: Postcode:
 
Managers name or other key personnel for contact:
    
Trade References:    
(1)
Contact: Phone:  
 
(2)
Contact: Phone:  
   
Your Bank: Branch: Phone:  
   
NHS Approval Number:    
PARTNERSHIPS – One partner must sign
I hereby certify that the above particulars are true and correct in every detail. I have read and agree to the terms and conditions of sale as outlined on this application. I am aware that payment terms for future purchases are thirty (30) days from the end of the month in which the purchases are made. I agree to abide by all trading terms as specified by this company hereon.
* Signed By:
  
Date:
 

 

 

  |   © Manrex Pty Ltd (ABN: 63 074 388 088) T/as Webstercare  - 2008