Belmont Client Information Form

Please enter the contact details for your facility.

* Facility Name:

* Address:

* Telephone:

Fax:

Website Address:

Please tell us a little more about your business.

Are you a Limited Company Sole Trader Partnership

* Company Name:

Company Number:

Registered Address:

* Name of Owner/Director:

Name of Owner/Director 2:

Name of Owner/Director 3:

We send reports via e-mail - Please provide names and addresses.

* Name (Membership Advices):

* Email Address:

Name (Payment Advices):

Email Address:

Approx. no. of live Direct Debits:

Names of any other collection agencies used:

Emergency Cashflow Assistance Loan required? Yes No

Do you intend to use Harlands for new business?

Will you use Harlands? Yes No Not Sure

No. of agreements needed:

Please add any additional comments you feel may be of assistance.

Comments: