Application for Trading Account

Please fill the form in below to apply for an account with EBOS Healthcare.
NB. All sections marked with * are mandatory.
ABN(*)
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Nature of Business(*)
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Date Established(*)
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Registered Address(*)
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Delivery Address(*)
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Special Instructions
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Telephone(*)
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Mobile(*)
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Fax
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Email Address(*)
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Director or Owner Names(*)
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Doctor or Authorised Person Able To Order Scheduled Drugs
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If a Subsidiary Company or part of a Group, please provide name of Parent Company
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Please Note: For a credit account, estimated monthly spend should be above $500 per month.
Monthly Credit Amount Applied For:(*)
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Purchase Order Number Required
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Accounts:
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Email:
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Position:
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Phone No:
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Mobile:
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Fax No:
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Purchasing:
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Position:
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Email:
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Phone No:
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Mobile:
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Fax No:
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Medical-Clinical:
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Position:
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Phone:
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Mobile:
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Fax No:
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Please provide an email address for electronic invoicing:
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TRADE REFERENCES

Supplier 1
Name(*)
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Phone(*)
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Supplier 2
Name(*)
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Phone(*)
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Supplier 3
Name(*)
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Phone(*)
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TO ENSURE SUPPLY OF SCHEDULED PRODUCTS, THE HEALTH DEPARTMENT REQUIRES THAT EBOS HOLDS A CURRENT COPY OF EVIDENCE FOR AN AUTHORISED PRACTITIONER OR LICENSE HOLDER AT THE STATED ADDRESS. FOR EXAMPLE A COPY OF YOUR MEDICAL REGISTRATION OR POISONS LICENSE. PLEASE NOTE THAT COPIED OBTAINED FROM AHPRA WEBSITE MUST BE SIGNED BY THE PRACTITIONER.
DECLARATION
(*)
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(*)
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(*)
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(*)
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Do you wish to order Scheduled Items?(*)
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Medical Registration
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Privacy Statement
EBOS Group Limited collects and holds your personal information that it considers appropriate for the purposes of providing credit to the customer, including the administration and management of the customer’s accounts with EBOS Group Limited. For these purposes, you consent to the disclosure of the personal information to any third party. By completing the details on the credit application form, you consent to the collection and use of personal information.