| Tell us the name and ABN of your business? |
| Business Name* |
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| ABN* |
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| Business Address* |
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| How can we contact you? |
| Your Name* |
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| Business Phone* |
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| Business Fax |
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| Mobile |
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| Email* |
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| 1. Tell us about your business and customers: |
| Tell us about your business* |
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| 2. What is the name and home address of the owner(s) of your business? |
| 2.1 Owner 1 |
| Name and Home address* |
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| Is he/she * |
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| 2.2 Owner 2 |
| Name and Home address |
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| Is he/she |
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| 2.3 Owner 3 |
| Name and Home address |
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| Is he/she |
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| 3. Have the business or it's owner(s) had any payment defaults, court judgements, bankruptcy, etc? |
| Business?* |
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| If yes, please provide details:* |
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| Owner(s)?* |
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| If yes, please provide details:* |
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| 4. Are your sales made on normal credit terms (e.g. 30 Days)? |
| Normal Credit Terms* |
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| If no, please provide details:* |
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| 5. Are your sales mainly to repeat customers or to new customers each time? |
| My sales are mainly to...*
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| 6. How many of your customers currently owe you money and how much do they owe? |
| Number of Customers* |
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| Amount Owed* |
$ |
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| 7. Are any of your customers also significant suppliers to your business? |
| Are your customers also suppliers?* |
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| If yes, please provide details:* |
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| 8. Is there anything else you think we should know |
| Any other relevant information: |
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