CUSTOMER APPLICATION FORM

DATE INSTITUTIONS
 CUSTOMER INFORMATION SHEET
SPECIAL
ACCOUNTS
DATE CUSTOMER NUMBER

GENERAL INFORMATION

Customer Name

Home Address

E-mail address:
Tax Identification Number
Contact No/s: please attach 2x2 picture
(for single proprietorship
Birthday: Sex: Male Female Citizenship: only)

Civil Status: If married, Name of Spouse:

PRC License No. Validity Date:
Yrs. In Practice:
Single Practice: ______________________________ Group Practice: _____________________________
Business Name (if group practice):
Other Members in group practice:
Specialization (Primary)
Anaesthesiology Geriatric Medicine Pediatrics
Cardiology Hematology Psychiatry
Dentistry Internal Medicine Pulmonology
Dermatology Nephrology/Urology Radiology
EENT Neurology Rheumatology
Endocrinology OB-Gynecology Surgeon
Family Medicine Oncology Transplant Surgery
Gastroenterology Optometry/Opthalmology Veterinary
General Practitioner Orthopedics Others,
General Surgery Pathology please specify
______________________
Specialization (Secondary) :
DELIVERY INFORMATION
CLINIC 1:
Address:
Bldg. Name & Room No. Number and Street

Barangay/Subdivision/District Town/City Province

Number of Yrs. In Stay: _______________________ Zip code: _________________________________
Contact Person/Authorized Representative
Name: Position: Signature:
Email Address: Clinic hours:
Delivery Schedule/Time: Tel/Fax/ No./s:
Authorized Person to receive deliveries: Signature:
Name: Position:
Email Address: Tel/Fax/ No./s:

CLINIC 2:
Address:

Bldg. Name & Room No. Number and Street

Barangay/Subdivision/District Town/City Province

Number of Yrs. In Stay: _______________________ Zip code: _________________________________

Contact Person/Authorized Representative
Signature:
Name: Position:
Email Address: Clinic Hours:
Delivery Schedule/Time: Tel/Fax/ No./s:
Signature:
Name: Position:
Email Address: Tel/Fax/ No./s:
 COMPANIES WITH EXISTING CREDIT LINES
SUPPLIER NAME CONTACT PERSON CONTACT NUMBER

2
3
FINANCIAL INFORMATION
BANK AND BRANCH ACCOUNT TYPE/NUMBER BANK ACCOUNT NAME
1

3
PROPERTIES DESCRIPTION/LOCATION LATEST MARKET VALUE MORTGAGED TO
OWNED
Real Estate
(Land/Building)

Vehicles

Other Assets

REQUIRED SUPPORTING DOCUMENTS

Fully accomplished and signed CAF

Photocopy of valid PRC License ID

I/We hereby certify that all of the above information are true and correct.

Applicant

_______________________________________________ _________________________________________
Signature Over Printed Name Signature Over Printed Name

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

Credit Limit

Credit Term

CUSTOMER MAINTENANCE

Account Maintained by Date Account Reviewed by Date

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME