Credit Application

Quipsmart Trading Pty Ltd as trustee for Quipsmart Trading Trust trading as
ADAM HIRE AND SCAFFOLDING SERVICES and QUIPSMART (under licence) ABN 95 318 504 358

PO BOX 5361, MORDIALLOC VIC 3195
70 Governor Rd, Mordialloc VIC 3195
Ph: 1300 QUIPSMART (1300 784 776)

Applicant Business Details

FULL TRADING NAME

Is this Trading Name a Registered Business Name?

YES NO

REGISTERED COMPANY NAME

ACN/ARBN

ABN

BUSINESS ADDRESS

STATE

POST CODE

BUSINESS PREMISES

Owned Leased Mortgaged Rented

NATURE OF BUSINESS

DATE BUSINESS ESTABLISHED

BUSINESS STRUCTURE

Sole Trader Private Company Public Company Trust Partnership Co-operative Incorporated Association Government Authority

PAID UP CAPITAL OF COMPANY (if applicable) $

NO. OF EMPLOYEES

BANK

BRANCH

BSB NO.

ACCOUNT NO.

TRADING HISTORY

ANNUAL TURNOVER $

Is the most recent Balance Sheet available for review?

YES NO

Are assets of Business encumbered?

YES NO

AMOUNT $

TO WHOM

Are bad debts insured?

YES NO

CONTACT DETAILS

POSTAL ADDRESS (if different to above)

STATE

POST CODE

TELEPHONE

FAX

EMAIL

CONTACT PERSONS - Accounts

CONTACT PERSONS - Purchasing

Telephone

CREDIT REQUIRED

ESTIMATED AMOUNT OF MONTHLY CREDIT REQUIRED $

OWNERS' / DIRECTORS' DETAILS

NAME

PRIVATE ADDRESS

PHONE

DATE OF BIRTH

NAME

PRIVATE ADDRESS

PHONE

DATE OF BIRTH

INSOLVENCY

Have any of the directors or proprietors been bankrupt or associated with an insolvent company?

YES NO

IfYes,NAME

YEAR OF BANKRUPTCY / INSOLVENCY

TRADING REFERENCES

(Please provide the names, addresses and phone numbers of four (4) current references.)

NAME

ADDRESS

PHONE

CORPORATE TRUSTEE

Where the Applicant makes this application as a Trustee, it warrants and declares that it has the power and authority to make and execute this Credit Application and that all rights of indemnity which it now has or may have in the future or may otherwise have against the property of the Trust of which it is a Trustee or beneficiary or both, have not been modified or excluded as a result of any act, matter or document made or executed by it or as a result of any breach of fiduciary duty or in any other way. It warrants and declares further that it is has not released and shall not release in the future and shall not cause or permit to be released, lost or diminished in any manner whatsoever, any such rights of indemnity.

NAME OF TRUST

NAME OF TRUSTEE

ADDRESS OF TRUSTEE

DATE OF TRUST DEED

NAME OF SETTLOR

BENEFICIARIES OF TRUST

ACCEPTANCE

The Applicant applies to Quipsmart Trading Pty Ltd (ACN 127 077 409) ("Quipsmart") for credit. The Applicant acknowledges receipt of and accepts the present standard Terms and Conditions and acknowledges that the Terms and Conditions may be changed by Quipsmart from time to time, by written notice to the Applicant.

Where the Applicant makes this application as a trustee, and details of the trust are not provided as above, the below signatories agree to indemnify against any loss of money due to Quipsmart by the Applicant, unless and until details of the trust are provided.

I/We warrant that I am/we are authorised to sign this Credit Application on behalf of the Applicant.

NAME (Block letters)

POSITION

DATE

NAME (Block letters)

POSITION

DATE

PERSONAL GUARANTEE AND INDEMNITY

I/We note that the trading Terms and Conditions have been provided to us by Quipsmart and that I/we have read and understood them. In consideration of supplying goods on credit to the Applicant:

I/We (and if more than one, jointly and severally) agree that if the Applicant at any time fails to pay any money due to Quipsmart or fails to perform or observe any term or condition of credit or sale to be performed by the Applicant, I/we will forthwith pay to Quipsmart all money due and payable by the Applicant (or any subsequent owner of the business name of the Applicant) to Quipsmart. No demand by Quipsmart for payment shall be necessary.

I/We further agree to indemnify Quipsmart against any loss of money due to Quipsmart by the Applicant under or relating to any sale by or credit granted by Quipsmart to the Applicant (or any subsequent owner of the business name of the Applicant) including expenses and legal costs associated with the collection of outstanding monies and including any loss suffered by Quipsmart as a result of the Applicant's failure to perform or observe any term or condition of credit or sale. I/We now charge my/our interest in any real property registered in my/our name/s in favour of Quipsmart to secure this Guarantee and Indemnity and authorise the lodgement of a caveat to support this charge.

I/We (and if more than one, jointly and severally) agree that this Guarantee and Indemnity is a continuing Guarantee and Indemnity and will not be invalidated, released or discharged by any event which would or might so invalidate, release or discharge the Guarantee and Indemnity, including (but not limited to) the giving of time, the variation of the terms and conditions of credit or sale, the alteration of the composition of the Applicant or the release of the Applicant or any co-guarantor. I/We understand this Guarantee and Indemnity binds me/us personally.

NAME (Block letters)

WITNESS NAME (Block letters)

DATE

NAME (Block letters)

WITNESS NAME (Block letters)

DATE

CREDIT CARD DETAILS

CARD TYPE

CARD NO

EXPIRY DATE

CARDHOLDER'S NAME

I/We authorise Quipsmart Trading Pty Ltd until further notice to debit my credit card for amounts due arising from goods and services delivered on this account.

NAME

DATE

Credit Application