Personal Information

Please enter the name, email address and position within the company of the person completing this application.

Any questions relating to this application will be sent to this person, plus confirmation that the account has been approved.

Applicant Name*
Applicant Email*
Position*
Additional Email

Company Details

Your company name, registered address and company registration number should match those registered at companies house.

If your company is part of a larger company or group, please provide the holding company address.

Company Name*
Registered Business
Address*
Invoice Address*
Phone Number*
Fax Number*
Company Reg No.*
VAT No.*
Years Trading*
Holding Company
Address*
Trade Reference 1*
Trade Reference 2*

Accounts Details

Credit Limit
Required (€)*
Accounts Contact*
Accounts Email*
Invoice Email*

Connectix Contact

Please let us know who at Connectix referred you to the credit application form.

Current Point of
Contact at Connectix*
How did you find out
about Connectix