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Please complete the form below to create a Goldpine credit account. Once completed this account will be able to be used at any of Goldpine’s 22 stores across New Zealand, and will also benefit from the following:

· Preferential discounts off all purchases
· Interest free credit on your purchases

· Exclusive account holder offers
· No annual fees

Account Details

Your preferred store*:

Account Name*:

Entity Type*:

What best describes your business*:

Applicant Information

Applicant Name:

First Name*:

Middle Name:

Last Name*:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trade References (where available)

Supplier One:

Name of Supplier:

Address:

Phone:

Supplier Two:

Name of Supplier:

Address:

Phone:

Supplier Three:

Name of Supplier:

Address:

Phone:

Partner Information

Legal entity name (If different from account name):

Partner One Name

First Name*:

Middle Name:

Last Name*:

Residential Address*:

Gender*:

Date of Birth*:

(Must be 18 years old)

Partner Two Name

First Name*:

Middle Name:

Last Name*:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Partner Three Name

First Name:

Middle Name:

Last Name:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trade References (where available)

Supplier One

Name of Supplier:

Address:

Phone:

Supplier Two

Name of Supplier:

Address:

Phone:

Supplier Three

Name of Supplier:

Address:

Phone:

Joint Venture Information

Legal entity name (If different from account name):

JV Member One

First Name*:

Middle Name:

Last Name*:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

JV Member Two

First Name*:

Middle Name:

Last Name*:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

JV Member Three

First Name:

Middle Name:

Last Name:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trade References (where available)

Supplier One

Name of Supplier:

Address:

Phone:

Supplier Two

Name of Supplier:

Address:

Phone:

Supplier Three

Name of Supplier:

Address:

Phone:

Trustee Information

Legal entity name (If different from account name):

Trustee One

First Name*:

Middle Name:

Last Name*:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trustee Two

First Name*:

Middle Name:

Last Name*:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trustee Three

First Name:

Middle Name:

Last Name:

Residential Address:

Gender*:

Date of Birth*:

(Must be 18 years old)

Trade References (where available)

Supplier One

Name of Supplier:

Address:

Phone:

Supplier Two

Name of Supplier:

Address:

Phone:

Supplier Three

Name of Supplier:

Address:

Phone:

Company Information

Legal entity name (If different from account name):

Phone*:

Email*:

Trade References (where available)

Supplier One

Name of Supplier:

Address:

Phone:

Supplier Two

Name of Supplier:

Address:

Phone:

Supplier Three

Name of Supplier:

Address:

Phone:

Account Contact Details

Details of the person who is completing this form:

Title*:

First Name*:

Last Name*:

Email*:

Note that invoices will be emailed to this address, with only a packing slip printed at POS. Preferences here can be changed at any time at your preferred store

Phone Numbers:
Both PhonesMobile OnlyLandline Only

Mobile Phone Number*:

Landline Phone Number*:

Fax:

Web:

Account Contact Details

Details of the person who is completing this form:

Phone Numbers:

Both PhonesMobile OnlyLandline Only

Mobile Phone Number*:

Landline Phone Number*:

Fax:

Email*:

Note that invoices will be emailed to this address, with only a packing slip printed at POS. Preferences here can be changed at any time at your preferred store

Postal Address

Postal Address Finder*:

- Can't find address?
Yes

Postal Address Line 1 (Manual Entry)*:

Line 2:

Line 3:

Suburb:

Postcode:

City*:

Physical Address same as Postal Address: YesNo

Physical Address

Physical Address:

- Can't find address?
Yes

Physical Address Line 1 (Manual Entry)*:

Line 2:

Line 3:

Suburb:

Postcode:

City:

Expected activity

Estimated maximum monthly purchases*:
$

Promotions

Would you like to receive our monthly mailer and other marketing material?

Please select reason*:

Specify*:

Terms and Conditions

Yes, I accept the Terms and Conditions