New Customer Application Form — Computer Clinic NZ

Please fill out the below form with details about your company. This form will be directly sent to our system so we can register you on our system

GENERAL CONTACT DETAILS

Company name - Name in the invoice

Physical Address

Main Contact Name

Main LandLine / Contact number

(###)

###

####

Account Email Address

Purchase Order Number

(if there is one)

Branch details (if needed)

Branch Name

Onsite Contact Name

Landline / DDI (if different from main number)

(###)

###

####

Mobile

(###)

###

####

Email

Additional details

Entry & Parking instructions (especially if not obvious or tricky)

Gate Code / Door Code / Lock Box

Any other details needed

Terms and conditions

I have read and agreed to the

Onsite service charges

I have read and agreed to the

New account