Account Application Request

Please complete the required information below. Or download, fill in and return via email to info@rgmedical.com.au or Fax 03 9720 6178 as soon as possible so we can ensure all details are correct and avoid any delays in processing your application.

ACCOUNT APPLICATION REQUEST

Fields marked with an * are required

Section 1

Section 1: Business Details

Name (Company or Sole Trader) *

ABN # *

ACN #

Trading Name *

Phone Number *

Fax Number

Postal Address *

State *

Post Code *

Delivery Address

State

Post Code

Additional Delivery Addresses or Notes

Section 2: Contact Details

Section 2: Contact Details

Please advise the details for the e-invoices & e-statements

Accounts Payable Name *

Accounts Payable Phone Number *

Accounts Payable Email Address *

Purchasing / Nurse Name

Purchasing Phone Number *

Purchasing Email Address *

Section 3: Confirmation of Relevant Licences & Registration

Section 3: Confirmation of Relevant Licences & Registration

A copy of a current permit / licence must accompany this form for all delivery sites Pharmaceutical products cannot be supplied unless the below is completed.

Wholesale Licence # *

Date Issued *

Expiry Date *

Drug Licence / Permit #

Date Issued

Expiry Date

Principle Doctors Name

AHPRA Certificate of Medical Registration #

Date

Date Issued

Expiry Date

Name of authorised person *

I confirm I am the applicant/authorised person *

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