Application for Trading Account

To apply for a Trading Account with Pharmaco (NZ) Ltd, please complete the form below.

Note: Only Healthcare Professionals are eligible for a Trading Account.

Email Address *

Your password *

Repeat password *

Trading Name

Registered Name

Date of Registration

Registration Number

Authorised Capital ($)

Paid Up Capital ($)

Solicitors

Accountants

Website URL

Postal Address

Delivery Address

Special Instructions

Nature Of Business

Number of years trading as above business

Geographical area of trading

Current turnover ($)

Number of full-time staff

Estimated value of monthly purchases from Pharmaco ($)

Email address for Invoices / Credit notes

Email address for Statements

Phone

Fax

Accounts Person Contact Details

We would like an invoice with our goods

We would prefer a despatch note with our goods

We would like our invoice by email if not sent with the goods

Trade References

Company One

Company Name

Contact Name

Contact Title

Contact Phone

Company Two

Company Name

Contact Name

Contact Title

Contact Phone

We authorise Pharmaco to use the above details for normal business purposes, including the posting or faxing of price lists and promotional material.

Signed Digitally *