FOR AUSTRALIAN BUSINESSES ONLY!

TO DOWNLOAD AN APPLICATION IN ACROBAT READER 7 FORMAT CLICK HERE!

When you have completed the information on this form please fax to:

The Pain Relievers on: (07) 5495 2613

Trading Name*
Type of Business*
Briefly Describe your Business*
Number of Employees* Owner Operator
Business Address*
Postal Address*
City*
State*
Postcode*
Phone Number*
Fax Number
Contact Person/Department*
Email Address*
Website
BUSINESS REGISTRATION
If Yes, your Australian Business Number (ABN)
TYPE OF INFORMATION
Products of Interest


Jewellery
DISCLOSURE AGREEMENT
By entering your tick you acknowledge that the information supplied is true and accurate and that we may disclose this information to third parties in order to verify your eligibility to purchase wholesale.
The information supplied is true & accurate Please Tick
Any personal information submitted will be used solely for the purpose of processing enquiries and will not be traded, sold or misused. It is our policy to provide superior customer service and satisfaction, we therefore value your right to privacy. For more information please read our Privacy Policy.
 

When you have completed the information on this form please fax to:

The Pain Relievers on: (07) 5495 2613