CUSTOMER INFORMATION FORM CIF No.

(To be assigned by Specialty Drugstore)

Page 1 of 2
TO BE FILLED-UP BY CUSTOMER
Customer Number Type of Application Date of Application
New Update (U) /Renewal (R) If U/R, date of last purchase _____________

GENERAL INFORMATION
Single Practice Group Practice
If engaged in group practice, please select the local group:
Medical Clinic Maternity Lying-In Others, please specify __________________

Customer Name VAT Registered?

Home Address YES NO

Contact No.: Please attach 2x2 picture

Birthday: Sex: Civil Status: Citizenship: Credit Limit Applied for (Php)

PRC License No.: ______________ Validity Date: Yrs. in Practice:

TIN No.
Business Name (If Group Practice):

Cardiology Internal Medicine Optometry/ Opthalmology Rheumatology

Dermatology Nephrology/ Urology Orthopedics Transplant Surgery
Specialization (Primary)
General Practitioner OB-Gynecology Pediatrics Others, please specify
Gastroenterology Oncology Pulmonology
Specialization (Secondary)

DELIVERY ADDRESS/ES
Default Delivery / Business Address
Building Name & Room No.
Number & Street
Barangay or Subdivision
or District
Town / City
Province Zip Code Area Code
e-Mail Address
Telephone No./s
Fax No./s
Delivery Schedule
Clinic Hours Preferred Delivery Time
Name of Authorized Person / Representative and Contact Details
Name of Authorized Representative Contact Number

Other Delivery / Shipping Address (es)

Authorized Person / Preferred
Address (Please indicate complete address) Contact No. Clinic Hours
Representative Delivery Time
1

NOTE: Please attach latest sales invoice (original) from other suppliers/distributors.
FINANCIAL INFORMATION
Bank and Branch Account Type Bank Account Name
1
2

F.N. 032.A.2010.02
 CIF No.
CUSTOMER INFORMATION FORM
Page 2 of 2
AUTHORIZED SIGNATORIES
AUTHORIZED PERSON (S) TO ACCEPT DELIVERIES / SIGN INVOICES
Printed Name Designation/Position Full Signature Initial Contact No.

AUTHORIZED PERSON (S) TO SIGN CHEQUE/S

Printed Name Designation/Position Full Signature Initial Contact No.

Special Instructions / Requirements

WAIVER
I / We wish to apply as a customer of ______________________________. For this purpose/ I / We hereby certify that all of the above information are true
and correct.
I / We understood that all our purchases from ______________________________ shall be on COD until my credit application has been completed, reviewed
and approved. By signing this application form, I / We accept the terms and conditions as stated. In addition, I / We authorize
______________________________ representatives to make any inquiries necessary to process this application.

Applicant / Authorized Representatives:

Signature Over Printed Name Signature Over Printed Name

Designation Designation

To be accomplished by Specialty Drugstore

Documents Reviewed and Authenticated by: Date
Commercial Manager/ Senior Operations Supervisor

SIGNATURE OVER PRINTED NAME

CREDIT APPROVAL
Recommended By Approved By
Type Recommended Approved
(Signature Over Printed Name) (Signature Over Printed Name)

Credit Limit

Credit Term

Credit Policy

DOS Target

CUSTOMER MAINTENANCE
Account Maintained by Date Account Reviewed by Date

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

REQUIRED SUPPORTING DOCUMENTS

Fully Accomplished & signed CIF PRC Identification Card Mayor's Permit BIR Certificate of Registration
Single Practice √ √ √
Group Practice √ √ √ √
Notes:
1. All supporting documents shall be valid for the year of application.
2. Should a customer opted to pay in check, they are required to open an account in a bank with local/regional clearing.
F.N. 032A.2010.02