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Reseller Login
> Username
> Password
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Why Apply?
> Order products online
> Benefit from promotions
> Access our products
 
 
Reseller Application Form  

1) Your Details
First Name:
Surname:
ABN:
Trading As:
Address 1:
Address 2:
City:
State:
Postcode:
Landline Number:
Mobile Number:
Default Delivery Instructions: (please tick)
* Freight applies to every shipment

2) Contacts
Directors/Partners:
Accounts Contact Name:
Accounts Contact Email Address:
Purchasing Contact Name:
Purchasing Contact Email Address:

3) Recent Trade References
1. Name, Address, Telephone:
2. Name, Address, Telephone:
3. Name, Address, Telephone:

4) Website Login
Would you like a logon and password to our website? (Please tick)
Full Name of Nominated Website Administrator:
Administrator’s Email Address:
Requested Website User Password:
Retype Website User Password:
Would you like the facility to place orders via our website? (Please tick)
Password Recovery Question: (Tick one box only)

Password Recovery Answer:

5) Nature of Business
Please tick:


Or other

6) How did you hear about us?

7) Terms & Conditions
I/we hereby certify that the information supplied is correct in every detail and I/we agree to abide by the terms and conditions of accessing the baxit.com.au website as listed on the website (please click here to view the terms & conditions).

I/we understand that the terms and conditions of accessing the baxit.com.au website may change from time to time and that I/we will have read the Terms of Use prior to using the website.

Do you agree to the terms & conditions (tick yes to agree)




 

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