CASH ACCOUNT APPLICATION FORM

Name
Address
IC No
Contact No

Photocopy of IC (FOR PERSONAL ACCOUNT ONLY)

Photocopy of Annual Practicing Certificate (FOR DOCTOR/CLINIC/HOSPITAL)
Photocopy of Poison License (FOR PHARMACY)
Photocopy of SSM Document (FOR COMPANY)
I/We declare that the above information is true, correct and complete and is given to Apex Pharmacy Marketing Sdn
Bhd (hereafter “the Company”) for cash account opening purpose. I/We authorise and consent Apex Pharmacy
Marketing Sdn Bhd (the company) to collect, store, disclose, use, match , obtain and exchange the above personal
details and information furnished by us with any third party or service provider including but not limited to the above
trade references , credit reference agencies and banks and obtaining credit reports from such parties for the purposes
of fraud or crime prevention, audit and debt collection. We consent to the collected information being retained for as
long as there is business transactions dealings between the Company and I/us provided that my/our personal data is
permanently deleted once it is no longer required to fulfill its original purpose. We authorize the Company to make
such credit investigation as the Company sees fit, including contacting the above trade references and banks and
obtaining credit reports. We authorize all trade references, banks and credit reporting agencies to disclose to the
Company any and all information concerning the financial and credit history of my company and myself.

Customer Signature : ___________________

Date : _________________

Official Rubber Stamp: ___________________

For office use only

Approved by : ______________________

Created by : ________________________

Account No : _________________ ______