African Snakebite Institute – Debtor Take-On Form

Please complete the Debtor Take-On form below, in order for us to load all your company information onto our system.

Full Company Name (As it should appear on invoice)*
Company Registration No:*
VAT Registration No:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address:*
Procurement Contact Name:*
Procurement Email:*
Procurement Contact Number:*
Finance Department Details:
Accounts Payable Contact Name:*
Accounts Payable Contact Email Address:*
Accounts Payable Contact Number:*
Automated Invoice Submission Email Address:
Automated Statement Submission Email Address:
Do invoices need to be uploaded to a specific vendor / supplier portal (ie, Coupa, VCM, etc). If so, please advise which portal below:
Please indicate payment terms:*
- Upon receipt of invoice.
- End of month in which invoice is dated.
- 30 Days from date of receipt of invoice.
- 30 Days from date of receipt of statement.
Confirmation:
By completing this form, I hereby confirm that I am duly authorised to dispense above company information.*
- Agree
- Disagree
Form completed by:*
Email Address:*
Date completed:*
DD slash MM slash YYYY

Finance Department Details: