Business Membership

Please fill in your details below. Mandatory fields are marked *.

	Your Details
Title*
First Name*
Last Name*
Trading As (if not as an individual)
Address*
Postcode*
County*
Landline*
Mobile *
Email*
Occupation*
Local Store*
Vat Registered*	Yes No
VAT Registration Number:*
Desired Credit Limit:*
	Please supply details of two businesses that you trade with, for example a veterinary surgeon or builder's merchant, but excluding bank, credit card companies or utilities References
Company Name*
Company Address*
Company Postcode*
Company Telephone*
Company Name*
Company Address*
Company Postcode*
Company Telephone*
	Farm Information
CPPH (holding number)*
Herd/Flock Mark*
Number of Acres*
	Stock Details
Dairy Cows*
Dairy Youngstock*
Suckler Cows*
Beef Animals*
Sheep (Ewes)*
Pigs (Sows)*
Poultry*
Horses*
	Crop Details
Wheat*
Barley*
Oats*
Oilseed Crops*
Forage Maize*
Permanent Pasture *
Grass Leys *
	Declaration
	By ticking this box I/we hereby authorise and agree to opening a business membership account with Mole Avon Trading Ltd and agree to the terms & conditions stated at www.moleavon.co.uk/membership Contact from Mole Avon Country Stores in the forms of Email, Text, Telephone & Mail. Yes
	To prevent spam, please check the box that appears below *

Your Details