ITAD Customer Application Form Thank you for your interest in becoming a Flex IT ITAD customer. Following Supplier Due Diligence regulations and guidelines, we are asking our trade accounts to provide full details about their company and business. Please complete all fields below, tick the declaration statements and submit the form. After submitting the form we will reach out to you as soon as possible. * Required Field Are you already a customer of Flex IT Distribution?(Required) Yes No I don't know 1. Company and Contact DetailsCompany Name*(Required)Trading NameCustomer NumberParent CompaniesNature of the BusinessVisiting Address*(Required) Street Address City Zip / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Telephone numberWebsite URLChamber of Commerce No.*(Required)Chamber of Commerce extract*(Required)Accepted file types: pdf, jpg, gif, png, jpegformat, Max. file size: 128 MB. VAT Number*(Required)EU VAT Number*(Required)Bank Name*(Required)Bank City*(Required)Bank Account (IBAN)*(Required)Bank Account SWIFT/BIC*(Required)Preferred Language*(Required)Invoice Currency*(Required)Main Sales ContactPositionTelephone NumberEmail SalesAdmin Contact*(Required)PositionTelephone Number Admin*(Required)Email Admin*(Required)2. DeclarationThis form has been (digitally) filled in by an authorized person. By signing this form the Vendor explicitly states the above stated company data are complete and accurate and accepts the attached purchase conditions of Xeptor B.V. Please note that we will exclusively use the above filled bank accounts for payments to your company.*(Required) I hereby declare that I am authorized to declare to the following, and I confirm that the information provided is complete and correct. Name(Required)Position(Required)Authorized signature (Digital)(Required) Apply Signature Declaration:*(Required)I/We hereby declare that the information provided is complete and accurate. The terms and conditions and our Privacy Policy stated overleaf have been read and agreed to. All relevant enclosures as requested are included with this form. I/We understand that Flex IT will carry out regular checks to ensure creditworthiness is maintained. I confirm that I have read and agree to the above declaration. Legal Disclaimer: The received information will be treated confidentially and in accordance with the applicable data protection laws. We shall only disclose the information if such disclosure is required by law or by an order of any governmental body or regulatory authority or court of jurisdiction. Information which has been made available by third parties or has been independently developed by us shall for this purpose not qualify as confidential. 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