Trade Referral Programme Application Form

This form is only to receive your business account details to ensure you receive your $100 Trade Referral.

Please note, we will send your accounts team our Credit Application if you wish to set up an account with Pure Services.

Business Details

Full or Legal Name:*

Trading Name (If different from above):

Physical Address*

Street Address Suburb City Postal Code Country

Primary Contact Details

Primary Contact Name:*

First

Last

Position:*

Email address:*

Phone No:*

Mobile No:

Account Details

Billing Address:*

Street Address Suburb City Postal Code Country

Purchase Order Number:

Accounts Contact Name:*

First

Last

Contact No:*

Accounts Email Address:*

supportoffice@pureservices.nz