<p> Application to Advertise on Form: P-001 SAA Marketplace Version: 1.0 Date: 5-6-14 Page 1 of 1 </p><p>1. Certificate Holders Details (Details will appear on the Marketplace website) Company name: Company</p><p> address: Company</p><p>Website:</p><p>Contact Email: </p><p>Contact Name: </p><p>2. Consultant Details </p><p>Business name: </p><p>Postal address: </p><p>Contact Email: </p><p>Contact Name: </p><p>3. Product Details (Details will appear on the Marketplace website) Product</p><p> description: Main model</p><p> number/name: Electrical rating: If you wish to include a photo on the website, please supply with your application form.</p><p>4.Declaration by Applicant</p><p>Please include my product on the SAA Marketplace and agree to abide by the SAA Marketplace Terms and Conditions.</p><p>Authorised</p><p>Signature:</p><p>Name of</p><p>Signatory: Title of</p><p>Signatory: Date: </p><p>5. Payment Details *PLEASE NOTE: Payments made by Amex will incur an additional charge (Refer to the Schedule of Fees) Verification Code: Credit *Amex Visa MasterCard (Last 3 digits on rear of card or 4 digits on front of AMEX) Account Expiry Date: Number: Card Holders Name: (as shown on card) Signature of Amount to debit cardholder: credit card: $ Please refer to our Schedule of Fees document on our website for EFT details. EFT For Reference: Use 1st 4 letters of applicant name and the Approval Number Payment by EFT will incur an additional AUD20 fee. Please forward a remittance advice Email Application to: [email protected]</p>