Supplier Name*

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Salesperson*

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Customer Ltd co name/Co reg*

This field is mandatory

Customer contact name/telephone*

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Term (e.g 36 months) - Quarterly/Monthly (Q/M)*

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Invoice Value*

This field is mandatory

Equipment Details*

This field is mandatory

I hereby agree that this data will be stored and processed for the purpose of establishing contact with the end user if required. I can confirm I have permission to pass on client information and they are aware Azura may make contact.*

* Indicates required fields

Customer Proposal