RETAILER APPLICATION FORM

If you are a UK retailer applying for PayPoint please do not fill in this form. Go to this page.

Company name *
  

Headquarters address *
  

Headquarters telephone *
  

Point of sales address *
  

Point of sales telephone *
  

Contact person *
  

Position *
  

Company type *

Registration No. under the Trade Register *
  

Fiscal number *
  

Establishment year
  

No. of employees
  

No. of administrative employees
  

Main object of activity *
  

Turnover 2004 (RON) *
  

Turnover 2005 (RON) *
  

Which are the companies connected to you by association?

Name
  

Turnover *
  

Main shareholders
  

Bank name and address
  

IBAN code of the bank
  

Business references
Please provide the names and addresses of some companies where you have credit and with which you carry on frequent business relationships.

Name
  

Address
  

Number of sales points *
  

Type of sales points *

Estimated monthly circulation (RON) *
  

Maximum payment term requested is of (days) *
  

Payment is being performed with *

Date *
  

ADMINISTRATOR’s surname and first name *
  

Filled out by *
  

Note: Completion of this form does not imply selection as a PayPoint Agent.

Agent Locator