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MOS APPL Form

Connect Account Application

ACCOUNT APPLICATION FOR THE CONNECT ONLINE SUPERSTORE
Please complete as much detail as possible and select the submit button.
A member of our online team will email your user and password details to
enable you to use our online superstore facility.
** Denotes required fields.

**Company Name:
**Invoice Address:	Delivery address : (if different to invoice address)
**Buyer Name:	**Buyer Tel:
Buyer Fax No	**Buyer Email:
Account Contact:	Account Tel:
Account Fax No:	Account Email:
Nature of Business:	Years Trading :	Employees:
Password Req'd for Online Portal:	Confirm Password:

Trade Reference No 1	Trade Reference No 2
Company Name:	Company Name:
Address:	Address:
Telephone:	Telephone:
Notes/Comments

Please note that submission of this account application declares you have read and are in acceptance of our terms and conditions of trading.