Affiliates Application Form

^*Company Name:

^*Contact Name:

^*Telephone No:

Fax No:

Address:

Company Registration No:

VAT Number:

Mobile No:

^*Email address:

Web Address:

Post Code:

^*Your Business Type

Travel: Financial: Property:

Online: Business Services: Other:

Number of Offices & Outlets

Offices: Outlets: Online:

Area your business Covers

Regional: National: Other:

Reason for Branded Card:

^*Expected Number of Applicants: 500-999 1,000-2,499 2,500-4,999 5,000-9,999 10,000-49,999 50,000-999,999 100,000-249,999 250,000-499,99 50,0000+

Required Start Date: Show Calendar

Customer Invoicing Details

Purchase Order No:

Accounts Contact Name:

Telephone Number & Fax Number:

Invoicing Address:

Agreed Credit Limit £:

Set up Fee: Excluding VAT

Stationary Cost: Excluding VAT

Additional Charges: Excluding VAT