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Wholesaler Application

Your application will be processed within 1 working day.



Enter your details below.
( your details will be kept confidential at all times )

Registered Business Name:
*
ACN / ABN / NZ IRD:
Applicant Name:
'Customer' and/or 'Licensee'
*

User Name:
We suggest your email address
*

Password:
*
Business Type:
*
Expected purchases ($0,000) from Picone per month:

Do you have a retail and/or a web store?
Retail Store *
Web Store *
No *

Payment Method:
Credit Card *
Pre Payment *
Cheque/EFT/Direct Deposit/Forte Account *

Registered Business Address:
Address Line 1
*
Address Line 2
Suburb / Town
*
State
*
Postcode
*
Country:

Business Delivery Address:
Same As Above    Enter Address
Address Line 1
*
Address Line 2
Suburb / Town
*
State
*
Postcode
*
Country:
*

Owner / Director 1 First Name:
*
Owner / Director 1 Last Name:
*
Owner / Director 2 First Name:
Owner / Director 2 Last Name:


Owner / Director 1 Address:
Address Line 1
*
Address Line 2
Suburb / Town
*
State
*
Postcode
*
Country:
*

Owner / Director 2 Address:
Address Line 1
Address Line 2
Suburb / Town
State
Postcode

Country:

Owner / Director 1 Telephone
*
Owner / Director 1 Mobile
*
Owner / Director 2 Telephone
Owner / Director 2 Mobile

Business Telephone
*
Business Fax
Business Email
*
Business Website
*
Additional information in
support of your application:

Please note: You will be emailed a copy of this application.

By Clicking "Process Your Application" below, you are agreeing to these terms and conditions of sale and the Image & Data License Agreement (IDLA)



NOTE: PICONE GROUP AUSTRALASIA WILL NOT APPOINT RESELLERS WHO ARE TRADING OR INTENDING TO TRADE ANY OF PICONE'S PRODUCTS THROUGH INTERNET AUCTION SITES e.g. eBAY, TradeMe etc.