NEW ACCOUNT FORM

GLOBAL PHARMACEUTICALS  (UK) LTD

GLOBAL HOUSE

RED LION BUSINESS CENTRE

RED LION ROAD

TOLWORTH, SURBITON

Date:

SURREY KT6 7QD

TEL: 020 8974 2786   FAX: 020 8974 2788

TO BE COMPLETED IN BLOCK CAPITALS/ *PLEASE DELETE AS NECESSARY

*NEW ACCOUNT / INVOICE ADDRESS:

NEW DELIVERY ADDRESS:

NAME

NAME

ADDRESS

ADDRESS

POST CODE

POST CODE

TEL:

FAX:

TEL:

FAX:

PAYMENT CONTACT (STATE NAME):

REGISTERED OFFICE ADDRESS (IF LIMITED COMPANY):

REGISTERED NUMBER:

BANK DETAILS

BANK NAME

BRANCH ADDRESS

POST CODE

ACCOUNT NUMBER

SORT CODE

INITIAL ORDER VALUE £

ESTIMATED VALUE OF FUTURE BUSINESS PER MONTH  £

PAYMENT TERMS

WE NOTE THAT YOUR PAYMENT TERMS ARE 30 DAYS FROM DATE OF STATEMENT

SIGNATURE

PRINT NAME

POSITION

Rgistered Office: Global House, Unit 1, Red Lion Business Centre, Red Lion Road, Tolworth, Surbiton, Surrey KT6 7QD, England, UK,

Registered in England. Company Reg Number 898492, VAT Reg Number 468 7100 33,

Pharmaceuticals Wholesale Dealers Licence Number 0576/001, Manufactureres Licence Number (Assembly only) ML 0576/01