Customer Registration Form

Business Name
ABN / ACN
GST Number
Number of Years Trading
Website:
Holding Company / Parent Agency
Business Address

Street Address

City / SuburbState

Postcode
Is Billing Address the same as the Business Address?
If No please fill in the BILLING ADDRESS

Street Address

Street Address Line 2

City / SuburbState

Postcode
Does your organization require Purchase Order/s to be applied to your invoices?
Finance Contact Name

First NameLast Name
Finance Phone Number
Email Address(s) (for invoices and statements)
GST
DIRECTOR / AUTHORISED PERSON DETAILS

First NameLast Name
Director/ Authorised Person Details - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address / PO BOX (only required for sole proprietor / partnership)

Street Address

Street Address Line 2

CityState / Province

PO Box
ADDITIONAL AUTHORISED PERSON DETAILS

First NameLast Name
Director/ Authorized Person Details - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address / PO BOX (only required for sole proprietor / partnership)

Street Address

Street Address Line 2

CityState / Province

PO Box

XR Extreme Reach Services

XR Extreme Reach provide the below products. Please tick the most relevant to your business:
Broadcast Distribution- Linear TV, Radio, BVOD, Cinema, ClearAds & CAB, Digital Video
Print Distribution
Digital
User Registration # 1

First NameLast Name
Phone Number #1
Please enter a valid phone number
Position / Title #1
Email #1
User Registration #2

First NameLast Name
Position / Title #2
Phone Number #2
Please enter a valid phone number
Email #2
Signature

Clear
Name

First NameLast Name
Date

DayMonthYear
Date
If you've been working with an XR team member click here to let them know you've submitted the registration form.
Can you put the persons name down that you spoke to.

First NameLast Name
Should be Empty:

XR Extreme Reach Services