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162 Cross Keys Road
Salisbury South
South Australia 5106
T: +61 8 8182 1888
F: +61 8 8182 1899
www.bickfordsgroup.com.au

Pay Before Delivery and Credit Card Authorisation
By completing this form, you will be establishing a PBD (Pay Before Delivery) account with Bickford’s Australia Pty Ltd (12 932 246 834) and/or Vok Beverages Pty Ltd (95 100 599 362).
The card information provided will be used to take payment prior to the despatch of your order and confirmation of this payment will be emailed through to you.
If payment does not clear, the Team will contact you to discuss before releasing any stock.
Please ensure that you refer to the Terms and Conditions accepted below as relevant to each and every sale placed.

Sales Representative : *

Customer Details

ABN : *

Liquor Licence No :

Registered Name : *

Trading Name :

Accounts Contact

The contact details specified here will be used to contact you for invoices, payment receipts and payment issues.

Name : *

Phone : *

E-mail : *

Company Representative

Please provide the details of the authorised Company Representative completing this form

Name : *

Phone : *

E-mail : *

Delivery Address

Address : *

Country : *

State : *

Suburb : *

Postcode : *

Special Delivery Instructions

Comments :

Card Information

Card holder name : *

Card number : *

Card expiry : *

CVV : *

I understand that the information provided in this form will be securely encrypted and available for charging for future transactions on my account with Bickford’s Australia Pty Ltd (12 932 246 834) and/or Vok Beverages Pty Ltd (95 100 599 362).

I understand that I may cancel this authorisation at any time by contacting accountsreceivable@bickfords.net and that this authorisation will remain in effect until cancelled.

I have read, understood and accept the terms and conditions.