OTC Direct Limited Customer account application / amendment form

Transcription

1 OTC Direct Limited Customer account application / amendment form Please find attached all forms needed to open an account with OTC Direct Ltd. Please fax all forms to or to sales@otc-direct-ltd.com Please be aware that delays may be incurred if form is returned partially completed If can also to post these forms to Risk administrator C/o Customer Finance OTC Direct Ltd 43 Cox Lane Chessington FAQ s Q. Why do I have to complete my full address on page 2 as well as page 1? A. Page 2 is seen by a number of departments. Page 1 is only seen by our finance team. Your application will be processed correctly if both pages are completed.. Q. My application is taking longer than 5 days why is this? A. Most delays are preventable, by adding as much detail as possible. Most delays occur when data requested is not provided e.g. No figure is provided in the credit limit section. If you are unsure how to answer please contact us on the 0800 number listed above or your regular point of contact. Q. I don t wish to add one of the 3 pages attached is that an issue? A. If this is the case please let us know by adding this information in the reason for submitting form at the top of page 1. Q. I am not yet registered with the General Pharmaceutical Council what does this mean? A. In order to deliver we need a valid pharmacy registration number. Please send in any supporting information from the GHPC, if this number has not yet been generated.

2 Customer account application / amendment form ALL FIELDS with an ASTERISK * are mandatory. fields may result in a delay to account opening Form 1 of 3 Please attach trading Group Notification form & Direct Debit Form Contact Acct Manager at OTCd: ** Date of application: ** Reason for submitting form Additional comments / consideration (please note if one of the 3 forms is not attached) (please tick as appropriate) Open a new account ** Amend existing account (please state existing account number below) Customer details Company registered name / name of sole trader ** Re-activate old account (please state old account number below) * Trading name * Company number * Name of NHS licensee * Pharmacy Delivery * Name of main contact / * Number & street superintendent Town * Name of Superintendent * County * Superintendent Pharmacist * registered number * Pharmacy registered number * Telephone number * VAT number (EU Cuts. only) * Fax number address Customer profile Customer status please tick as appropriate Customer type please tick as appropriate Sole trader * Pharmacy * Partnership * Wholesaler / on-seller * Limited liability partnership * Dispensing doctor * Private limited company * Exporter * Public limited company * Private prescriptions only * Charity * General practitioner * Other (please state) * Other (please state) * Have there been any County / High Court Judgments or Insolvency proceedings against proprietors / directors / company within the last 3 years? * To set a relevant credit limit please estimate your monthly spend? (excluding VAT) Please note a delay may occur to the application if left blank * Do you require a Saturday delivery? (please Tick) YES NO Estimated Time? Ordering method (state all that apply: PMR, telephone, online) * Are you a member of a buying group (please state name & N o.) ** Please advise here & on attached form ** Do you have any other OTC Direct accounts? (Please state N o.) * Do you have an Alliance Healthcare account? (Please state N o.) * Responsible Persons Please return to Free Fax Sole trader / partner / director Second partner / director Full name * Full name * ** Title Home address Title Home address Telephone number * Telephone number * Date of birth Date of birth References Please return to Free Fax Statements attached [ ] or trade reference Second trade reference or supplier statement attached [ ] Name * Name * Telephone number Telephone number Authorisation Please return to Free Fax By signing and returning this application form, you consent to using and keeping information provided by you to search the records held by credit reference and fraud prevention agencies ( Agencies ) or by third parties such as credit reference agencies, professional bodies and others named on this form relating to your application, when considering your application and at other times during your relationship with. You agree and understand that the Agencies will record our search even if this application does not proceed and you consent to us obtaining such information from Agencies, professional bodies and others name on this form to determine if we should proceed with your application. You consent to and its affiliates processing including, without limitation, storing sharing with, or selling to, any of its affiliates and any other third party: (a) your name and the name, address and telephone number of the business; and (b) any information relating to the volume of products, by manufacturer, supplied to me or the business by or any of its affiliates that may be held by or any of its affiliates from time to time. You understand that and its affiliates will comply with the Data Protection Act 1998 in processing your personal information. We may use your information to let you know about other products and services offered by OTC Direct Limited and other companies in the Walgreens Boots Alliance Group which we think will be of interest to you. If at any time you wish to stop receiving this information from us, please write to Sales Department, 43 Cox Lane, Chessington. We may also sell, trade or rent your information to third parties. By singing and returning this application you consent to this use. Please initial in the right hand box provided confirm you understand Authorisation Place Initials here: PLEASE SEE PAGE 2 FOR SIGNATURE NEEDED

3 Authorisation - I/We hereby apply for credit terms with and agree to be bound by your terms and conditions of sale. The above details are correct to the best of my/our knowledge. Proprietor s / director s signature***** Name**** Date**** Trading Group Notification Form fields may result in a delay to account opening Form 2 of 3 Please attach Customer Account Application + Direct Debit Form Please return to Free Fax please ensure form 2 & 3 are attached All fields marked with an asterisk * are mandatory fields may result in a delay to your account settings / availability to order Account Details Please return to Free Fax OTC Direct ACCOUNT NUMBER Please leave blank if not known If this is a new account application, please place a tick here: ADDRESS * POSTCODE * TELEPHONE & ADDRESS Trading Group Details Please return to Free Fax Name of Trading Group your pharmacy is part of * - -If not affiliated to a trading group please write independent Trading Group Acc No: Please leave blank if not known I authorize OTC Direct to flag my account as a member of the above stated trading group I authorize OTC Direct to share with the trading group my sales data with OTC Direct. I understand that it is my responsibility to inform OTC Direct if I wish for my trading group to be changed at a later date. I understand that I can only be flagged as a member of one trading group with OTC Direct Please return this form via fax or to sales@otc-direct-ltd.com Alternatively return directly to your account manager or regular point of contact. SIGNATURE * PRINT NAME * DATE * Please call the sales team on if you have any questions Please ensure form 1 & 3 are attached

4 Direct Debit Form fields may result in a delay to account opening Form 3 of 3 Please attach Customer Account Application + Trading Group Notification Form 43 Cox Lane, Chessington, Surrey, Telephone Fax Please fill in the whole form using a ball point pen and send to: Credit Control OTC Direct Ltd 43 Cox Lane Chessington Surrey Instruction to your Bank or Building Society to pay by Direct Debit Reference Name(s) of Account Holder(s) Bank/Building Society account number Instruction to your Bank or Building Society Please pay OTC Direct Ltd Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with OTC Direct Ltd and, if so details will be passed electronically to my Bank/Building Society. Branch Sort Code Name and full postal address of your Bank or Building Society To: The Manager Bank/Building Society Signature(s) Date Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts ser This guarantee should be detailed and retained by the payer The Direct Debit Guarantee This Guarantee is offered by all Banks and Building Societies that take accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit will notify you within 10 working days in advance of your account being debited or as otherwise agreed. If you request to collect a payment, confirmation of the amount and date will be given to you at the time of request If an error is made in the payment of your Direct Debit, by OTC Direct Ltd or your Bank or Building Society, you are guaranteed a full and immediate refund of the amount paid from your bank or building society If you receive a refund you are not entitled to, you must pay it back when asks you to

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