Account Application

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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Postcode(*)

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Country(*)

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Delivery Address(*)

sameas 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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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(*)

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(*)

Yes

Registration certificate

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Anti Spam Filter(*)

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Account Application Form

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