ZPC OFFICIAL FORMS REF: ZOF

CUSTOMER APPLICATION FORM (CAF)

FORM SPECIFICATIONS

Name Customer Application Form (CAF) Form Number F.N. 022.2010.05

Number of copies 2 Padded Loose Leaf Continuous Form Number of sets per pad (if padded)
Prenumbered Comments/Description/Printing Instructions:
Numbering Structure: N/A Need not be pre-printed.

Sample format
Copies Size Color Paper Quality
reference
1 8 1/2 X 11 inches White standard bond paper Attachment 1
2 8 1/2 X 11 inches White standard bond paper Attachment 1
Prepared by: Role Signature Date

MARIE ANNE S. FERRERIA ZPC SOAR System Integration

and Documentation Team Lead
Assistant Corporate Systems Manager
(Back-up)

DIWATA N. DE LEON ZPC SOAR System Integration

Corporate Systems Manager and Documentation Team Lead

Reviewed and Endorsed by: Role Signature Date

JOSEPH ANTHONY F. ROSELLO Subject Matter Expert and ZPC

SOAR Sales Functional Team
Account Manager
Member

JEOGLIN T. CASINILLO ZPC SOAR Sales

Group Sales Manager Stream Lead

JINKY M. MENDOZA Subject Matter Expert and ZPC

SOAR Operations Functional
File Maintenance Officer
Team Member

MA. ROWENA GRACE B. BELEN ZPC SOAR Operations Stream

Manager - Customer Service & Business Development Lead

GARRY B. GALVEZ
Subject Matter Expert
Supply Chain Director

MA. CRISTINA C. MONTALVO

Subject Matter Expert
Branch and Transportation Network Director

MA. TESSA N. FLOJO

Subject Matter Expert
Credit Manager

RIZZA B. PASCUAL
Subject Matter Expert
Branch Credit Manager

EUGENE M. BALAYAN ZPC SOAR Finance

Operations Controller Stream Lead

JOEL R. DUCUT
ZPC SOAR Team Lead
Assistant Corporate Controller
Approved by: Role Signature Date

MARIA VISITACION I. BARREIRO ZPC SOAR OCM Team Lead

AVP - Corporate Controller (Back-up)

DANILO J. CAHOY ZPC SOAR Steering Committee

VP - Sales Team 1 Member

MANUEL J. CONCIO III ZPC SOAR Steering Committee

VP - Sales Team 1 Member

ASHLEY GERARD S. ANTONIO ZPC SOAR Steering Committee

VP - Distribution Member

JOSEPH NATHANIEL B. AGUILAR ZPC SOAR

Chief Operations Officer Project Sponsor
 CAF No.

CUSTOMER APPLICATION FORM

(To be assigned by Zuellig Pharma)

Page 1 of 4

To be accomplished by ZUELLIG PHARMA

Prospect Customer / Customer Type of Application Date of Application
Number
New Update (U)/Renewal (R), please indicate date of last purchase ____________

BUSINESS INFORMATION
TIN
VAT Registered?
Business Name
YES If yes:
12% VAT
Zero-rated
Business Ownership Single Proprietorship Partnership Corporation
(Please check one) NO Please attach 2x2 picture
(for Single Proprietor only)

Requires Delivery (to be filled out by Zuellig Pharma)

Yes No Transportation Zone
Receipt?
Building Code Room Floor
Number & Street 1
Street 2
Business Address and
Business Contact District
Numbers
Zip Code City

Region GMA (Greater Manila Area) LUZ (Luzon) MIN (Mindanao) VIS (Visayas)

e-Mail Address Cellular Phone No.

Telephone No./s Fax No./s
Contact ID
Contact Person Name (to be filled out by Zuellig Pharma)
(Kindly add additional sheet if there is
more than one)
Position

Business Registration No. of Years in Business No. of Stores/ Branches

(if any)
Drugstore Clinic Distributors
Hospital Wholesalers Others, please specify _________________
Capitalization (Php) Credit Limit Applied For (per this application) (Php) Do you have other/existing accounts with ZP?
Yes No If yes, how many? ___________

OWNERS' PROFILE (Information about the Owners or Shareholders)

Contact % Interest
Name Home Address Citizenship Occupation
Number Share
1

OTHER BUSINESS INTEREST OF OWNERS

Name of Company Business Ownership Nature of Business Address
(Sole Proprietorship, Partnership or Corporation) (Manufacturing, Construction, Services, etc.)

5
NOTE: Please attach latest sales invoice (original) from other suppliers/distributors.
F.N. 022.2010.05
 CAF No.

Page 2 of 4

BUSINESS INFORMATION
Additional Contact Persons
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position

Additional Delivery or Shipping Address

(to be filled out by Zuellig (to be filled out by Zuellig
Requires Delivery Yes Prospect Ship-to / Pharma) Transportation Pharma)
Receipt? No Ship-to Number Zone

Building Code Room Floor

Number & Street 1
Address and Contact Street 2
Numbers District
Zip Code City
Region GMA (Greater Manila Area) LUZ (Luzon) MIN (Mindanao) VIS (Visayas)
e-Mail Address Cellular Phone No.
Telephone No./s Fax No./s
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
(to be filled out by Zuellig (to be filled out by Zuellig
Requires Delivery Yes Prospect Ship-to / Pharma) Transportation Pharma)
Receipt? No Ship-to Number Zone

Building Code Room Floor

Number & Street 1
Address and Contact Street 2
Numbers District
Zip Code City
Region GMA (Greater Manila Area) LUZ (Luzon) MIN (Mindanao) VIS (Visayas)
e-Mail Address Cellular Phone No.
Telephone No./s Fax No./s
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
(to be filled out by Zuellig (to be filled out by Zuellig
Requires Delivery Yes Prospect Ship-to / Pharma) Transportation Pharma)
Receipt? No Ship-to Number Zone

Building Code Room Floor

Number & Street 1
Address and Contact Street 2
Numbers District
Zip Code City
Region GMA (Greater Manila Area) LUZ (Luzon) MIN (Mindanao) VIS (Visayas)
e-Mail Address Cellular Phone No.
Telephone No./s Fax No./s
Contact ID
Name (to be filled out by Zuellig Pharma)
Contact Person
Position
Note: For Pharma Customers, each delivery / shipping address must be supported by valid FDA/DOH permit.
F.N. 022.2010.05
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CAF No.

Page 2 of 4

FINANCIAL INFORMATION
Bank and Branch Account Type

Properties Owned Description/Location Latest Market Value Mortgaged To

Real Estate (Land/Building)

Vehicles

Equipment/Machineries

Shares of Stocks

Other Assets

OTHER INFORMATION
Existing Letter/s of Credit (LC), if any. (Please specify Amount/Bank/Expiry Date) Do you have existing contract/s with Principal/s? Yes No
If yes, please specify principal name: ________________________

AUTHORIZED SIGNATORIES
AUTHORIZED PERSON(S) TO SIGN SALES ORDER
Printed Name Designation/Position Full Signature Initials Contact No.

AUTHORIZED PERSON(S) TO ACCEPT DELIVERIES / SIGN INVOICES

Printed Name Designation/Position Full Signature Initials Contact No.

AUTHORIZED PERSON(S) TO SIGN CHEQUES

Printed Name Designation/Position Full Signature Initials Contact No.

Special Instructions / Requirements

Note: Please see Attachment A for Required Documents

BUSINESS REFERENCES (Companies/Suppliers/Distributors with whom I/we do business on credit at present)

No. of Average Monthly
Company/Supplier/Distributor Address Telephone No. Credit Limit
Years Purchases

F.N. 022.2010.05
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Page 4 of 4

WAIVER
I / We wish to apply as a customer of Zuellig Pharma Corporation (ZPC). 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 ZPC shall be on Cash on Delivery (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 ZPC 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 ZUELLIG PHARMA

SALES DATA
Sales Office Delivering Plant
SUBMITTED BY CHECKED AND ENDORSED BY
Sales Representative Branch Interactive Circle (BIC) Head

Signature Over Printed Name / Date Signature Over Printed Name / Date

CREDIT APPROVAL
Type Recommended Recommended By Approved Approved By

Cash Management Group

Signature Over Printed Name Signature Over Printed Name

Credit Limit
Signature Over Printed Name Signature Over Printed Name

Terms of Payment
Signature Over Printed Name Signature Over Printed Name

CUSTOMER MAINTENANCE
CUSTOMER CLASSIFICATION
Customer Local Group Industry Code 2 Industry Code 4
Industry Code 1 Industry Code 3 Industry Code 5
RECOMMENDED BY APPROVED BY
Credit Supervisor Credit Manager

Signature Over Printed Name / Date Signature Over Printed Name / Date

CORRESPONDENCE
Accounting Clerk E-mail Address

WITHHOLDING TAX
Subject to tax? NO YES Tax Type ________ Tax Code _______

APPROVALS
REVIEWED BY (TRANSPORTATION) REVIEWED BY (LICENSE)
Transportation Manager Pharmacist / Regulatory Affairs and QA Manager

Signature Over Printed Name / Date Signature Over Printed Name / Date
REVIEWED BY (CUSTOMER ACCOUNT MANAGEMENT GROUP) REVIEWED BY (FINANCE)
Accounts Receivable Controller / National Sales Manager, Accounts Receivable Accounting Supervisor / Assistant Corporate Controller

Signature Over Printed Name / Date Signature Over Printed Name / Date
MAINTAINED BY VALIDATED BY
File Maintenance Analyst / File Maintenance Officer File Maintenance Analyst / File Maintenance Officer

Signature Over Printed Name / Date Signature Over Printed Name / Date
F.N. 022.2010.05
 Attachment A

The following are the required documents for new customers:

Board
Resolution or
Fully DTI Certificate Standby LC Latest Audited Secretary's
BIR VAT Secondary
Accomplished BFAD Mayor's Permit of Registration/ from Financial Certificate
Customer Channel (whenever Certificate License
and LTO (whenever SEC (for purchased Accredited Statement and
applicable) Articles of
Signed CAF applicable) Registration Regulated Drugs) Banks and ITR
Incorporation
(for Corporations
Only)

1. Drugstores
If Purchasing
(Chain, Independent, √ √ √ √ √ Regulated Drugs √ √
Wholesalers)

2. Hospitals
If Purchasing
(Private, Government, √ √ √ √ √ Regulated Drugs √ √
Clinics)

3. Pharma Wholesalers
and Sub distributors If Purchasing
(Medical and Dental √ √ √ √ √ Regulated Drugs √ √ √
Doctors, Optical Clinics, etc.

4. Modern Trade
Channels
(Chain & Independent
Consumer Stores such as √ √ √ √ √ √
supermarkets,
groceries/stores,
Department Stores, etc.)

5. Modern Trade
Wholesalers and Sub √ √ √ √ √ √ √
distributors

6. Others
(Institutions, Socio-Civic Whenever Whenever
Organizations, Govt. √ Applicable Applicable √ √ √
Entities)

Notes:
1. All supporting documents shall be valid for the year of application.
2. If the following required documents are not submitted during account opening, order may still be served under cash basis only:
- Board Resolution or Secretary's Certificate and Articles of Incorporation (for Corporations only)
- Latest Audited Financial Statement
- ITR
3. Should a customer opt to pay in check, they are required to open an account in a bank with local/regional clearing.
4. For Industrial Account - whenever applicable should provide PEZA Registration and PEZA Certificate.
5. VAT Registered Customers - no order can be processed until Certificate of Registration is submitted.
6. VAT Registered Zero-Rated Customers - no order can be processed until Certificate of Zero-Rated Sales is submitted.