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Account Application Form
All information submitted via this form will be treated as strictly confidential. Please complete all the required fields* in this form and press the submit button. Your application will be processed within 7 days.
Email Address
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Date
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Name of Applicant or Business
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Number and Street
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City
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State
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ACT
NSW
NT
QLD
SA
TAS
VIC
WA
South Island
North Island
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Postcode
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Country
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Australia
New Zealand
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Delivery Address
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as follows
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As Follows
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Phone
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Fax
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Directors Names
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Type
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Optometrist
Ophthalmologist
Optical Dispenser
Orthoptist
Private Hospital
Government
Other
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ACN
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Therapeutics registration number
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Provider Number
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Business Established
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Preferred Payment Option
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Direct Deposit
Cheque
Amex
Mastercard
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Other
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Other
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Trade Reference 1
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Phone 1
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Trade Reference 2
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Phone 2
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Trade Reference 3
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Phone 3
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Expected Monthly Purchases
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I/we agree to OptiMed's
Terms and Conditions
I/we hereby agree to pay all accounts on a strictly 30 days from invoice basis unless otherwise stated on the official invoice and in accordance with our standard terms and conditions. I/we understand that , should payment not be made according to these terms, the account facility will be revoked. I/we also agree that all the information contained within this application form is true. By submitting this form you agree to all these conditions. * To purchase certain licenced pharmaceuticals ( therapeutics in particular) you will be required to submit a copy of your registration certificate.
I agree to the terms and conditions
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Yes
Yes
Registration certificate
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Anti Spam Filter
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