Account Application Form

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Postal Address
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Delivery Address
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Details of Directors/Owners
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Trade References (please complete for 20 day accounts)
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Marketing
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Statements
Please supply the following information for your Accounts Department:
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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.
TO ENABLE SUPPLY OF PHARMACEUTICALS/VACCINES/LOCAL ANAESTHETICS THE HEALTH DEPARTMENT REQUIRES US TO HAVE A COPY OF EITHER YOUR MEDICAL REGISTRATION OR LICENSE TO SUPPLY SCHEDULED ITEMS. NOTE: AHPRA COPIES MUST BE SIGNED BY THE LICENSE HOLDER.
PLEASE NOTE: YOU MUST INCLUDE YOUR MEDICAL REGISTRATION FOR SCHEDULED DRUG PURCHASES.
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