Customer application form for use of cylinders

surname * (person responsible for ordering supplies)

first name *

company registration number *

town/city *

eircode *

county *

mobile *

landline telephone *

email *

electronic correspondence *

I wish to receive invoices and statements electronically via email?

yes no

I/we confirm that product will be delivered and received at the above address

I/We confirm receipt of safety leaflet and am aware that SAFETY INFORMATION on the gases received including transport and storage can be viewed and downloaded from the Irish Oxygen website (irishoxygen.com)

I/we agree to keep the cylinders in good condition and will be responsible for any damage caused to them or by their use. I/We will return all cylinders to Irish Oxygen Company Ltd at my/our own expense immediately when they are empty, or should I/we cease to use them, but in any case, within 12 months of the date of issue.

If a credit account is approved, all invoices must be paid within 30 days from end of month and are subject to the terms of the European Communities (Late Payment in Commercial Transactions) Regulations 2012 (as amended) and I/we agree to pay interest and compensation on any late payments as set out by these regulations.

Irish Oxygen complies with EU General Data Protection Regulations and business data is held on customers. An individual is entitled to review his/her data and have it corrected or removed as appropriate.

I AGREE TO RECEIVE UPDATES / REMINDERS BY MESSAGE TO MY PHONE

medicinal products *

Is the supply of medicinal gases required ?
If yes, an additional form (FM.16) must be completed and submitted.

yes no

customer's signature * Use mouse or trackpad

date

Customer Account No.

Processed by (staff initials)

By signing this mandate form, you authorise (A) Irish Oxygen Company Ltd to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Irish Oxygen Company Ltd.

As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.

city

eircode

country

debtor account number - IBAN *

creditor name

creditor identifier

city

post code

country

type of payment
recurrent payment
or
one-off payment

signature(s) * Use mouse or trackpad

date

Customer application form for use of cylinders

Please complete all fields marked *

IRISH OXYGEN USE ONLY

SEPA DIRECT DEBIT MANDATE

Unique Mandate Reference (UMR) - to be completed by Irish Oxygen