Retail Affiliation Application Form for MULTI SITES

Business Name: *
Business Type: *
e.g. Grocery, GP Surgery, Osteopath...
Contact Name; Title: *
Contact Person; First Name: *
Contact Person; Last Name: *
Email: *
Business Address: *
Business Address:
Business Address:
Business Address; Town / City: *
Business Address; Postcode: *
UK VAT number (If applicable):
Number of sites: *
Sites Postcodes: *
Each postcode in new line
I have read and agree to the Terms & Condition:  *
Additional message:
Bank name:
Bank sort code:
Account number:
Account name:
 *
Please add the two numbers