Supplier Membership Application Form

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APPLICANT ORGANISATION
Organisation Name
Australian Business Number (ABN)
Is your business conducted
- From Premises / Offices in One State Only
- From Premises / Offices in Multiple States
- From International Premises / Offices
Registered Office
Registered Office
Address Line 1 Address Line 2 Suburb State / Province / Region Postal / Zip Code Country
Business Address
(if different to registered office)
Business Address
Address Line 1 Address Line 2 Suburb State / Province / Region Postal / Zip Code Country
Postal Address
Postal Address
Address Line 1 Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Details
Website
Generic Email
Phone
(Please include country & area code)
Fax

(Please include country & area code)
Company Logo (High Resolution PNG preferred)
Max. file size: 128 MB.
Please provide a short introduction of your company:
Please confirm the above information and proceed to the next section
- Yes
- No

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CEO Details
Name of Chief Executive
First Last
Position / Title
Email
Authorised Representative
(The DSA Constitution requires Supplier Member organisations to nominate a natural person to represent and bind the member in its dealing with the Association)
Name of Proposed Authorised Representative
First Last
Position / Title
Email
Direct Phone
(Please include country and area code)
Mobile
Accounts Contact
Name of Accounts Contact
First Last
Position / Title
Email
Direct Phone
(Please include country and area code)
Mobile
Please confirm the above information and proceed to the next section
- Yes
- No

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REFERRING DSA MEMBER ORGANISATION
(Applicants for Supplier Membership must nominate a referral contact with whom they have an established business relationship. If you have worked with one of our Members, please provide their details as referees in support of your application).
Have you previously worked with a DSA Member? If yes, please fill out the Member information below. If no, please provide information from one of your clients that would be willing to speaks with us on your behalf.*
- Yes
- No
Referral Company Name
Contact Name
First Last
Position / Title
Email
Phone
Mobile Phone
(Please include country and area code)
Please confirm the above information and proceed to the next section
- Yes
- No

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DECLARATION*
I am the proposed Authorised Representative and authorised to make this declaration
- To the best of my knowledge and belief the Applicant’s business operations complies with relevant law.
- The Applicant agrees as a condition of Membership to comply with the Association’s Constitution.
- The Applicant agrees as a condition of Membership to promptly inform the Association of any change in its circumstances including that of the authorised representative.
Full Name*
First Last
Date
DD slash MM slash YYYY

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WEBSITE LISTING
Please email your company logo to [email protected] if file is larger than the approved sizing below.
File size: Less than 1MB. Preferred file format: JPG or PNG
Phone
Email
Website
Address
Address Line 1 Address Line 2 City State / Province / Region Postal / Zip Code Country
Company Description
Link to any promotional video that you would like to include in the listing (YouTube, Vimeo etc.) or upload a file below.
File Upload
Drop files here or

Accepted file types: mp4, mov, wmv, Max. file size: 256 MB, Max. files: 2.

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APPLICANT ORGANISATION