Registration form new customer

Registration form

Please fill in this customer form carefully, so that we can create a client account and client number in our ERP system.

1. Company name *

2. Name contactperson *

3. Type of organisation *

4a. Street and number visiting address *

4b. Postal code and place *

4c. Province and land *

5a. Telephone number *

5b. Mobile number

6. General e-mailaddress *

7. E-mailaddress for orderconfirmation *

8. E-mailaddress for the invoice *

9. Website address

10a. Chamber of commerce number

10b. VAT number (not mandatory outside EU)

11a. Do you have a delivery address other than your visiting address?

Yes, also fill in 11b to 11e. No, go to 12.

11b. Company name delivery address

11c. Street and number delivery address

11d. Postal code and place deliveryaddress

11e. Telephonenumber delivery address

12a. Do you have an invoice address other than your visiting address?

Yes, also fill in 12b to 12e. No, go to 13.

12b. Company name invoice address

12c. Street and number invoice address

12d. Postal code and places invoice address

12e. Telephone number invoice address

13a. Are you a member of a purchasing organization (which is important for invoicing)? *

Yes, go to 13b. No, go to 14.

13b. Wat is de naam van de inkooporganisatie?

13c. Who is the contact person for payments / administration?

13d. What is the email address for payment / administration contact?

14. Do you have any questions or comments?

15. Read our general terms of delivery and payment. Do you agree with the general terms and conditions of delivery and payment that apply to first and subsequent follow-up orders, deliveries and agreements, as stated in the link? *

16. Read our privacy policy. Have you read the privacy policy in the link? *

Dyna Dental uses upfront payment. Once you place an order, you will receive a proforma invoice. When the amount is in our account, the order will be shipped.

Registration form new customer

Registration form

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