Distributors

Application For Credit:

Registered Name: *

Trading Name: *

Physical Address:

Building Name: *

Street Name: *

Suburb: *

City: *

Province: *

Code: *

Postal Address: *

Postal Code: *

Telephone: *

Fax:

Cellular:

Email Address: *

Date Established: *

Vat Registration No.: *

Are you Trading as a: *

Pharmacy
Pharmaceutical Wholesaler
Hospital
Nursing Sister
Doctor
Other

If other, please specify:

Registered No.: *

Dispensing License No.: *

Name of Responsible Pharmacist: *

Registration of Responsible Pharmacist: *

Sole Owners (and/or firm) and Partnership: Full name and home address or Owner/Partners:

1. Name and address:

1. Telephone No.:

1. Identity No.:

2. Name and address:

2. Telephone No.:

2. Identity No.:

3. Name and address:

3. Telephone No.:

3. Identity No.:

Date Business Started:

Date of Business Purchased:

General:

Name of Owner:

Are there any notarial bonds or cessions over the assets of the:

Business:

Auditors:

Bankers:

Branch:

Account No.:

Name and capacity of person authorised to order:

Name of person handling accounts, queries, etc:

Amount of credit applied for:

Distributors Application For Credit

Company Info

Customer Services

My Account

Our Offers