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Application Form

Company name:

Kind of customer:

Training drugstore?:

yes no

Medical license?:

yes no

Memberships of professional associations
(with membership number):

Contact:

Afleveradres

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Town/village:
Streetname:
Housenr.:

Factuuradres (indien afwijkend van afleveradres)

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Town/village:
Streetname:
Housenr.:

Telephonenr.:

E-mail contact:

E-mail invoices:

E-mail newsletters:

Website:

VAT number:

Registration number and place VAT:

Copy VAT extract (JPG or PDF file):

After the registration, we will send an authorization for direct debit. For direct debit, a 1% discount will apply to invoice (we collect within 5 days of invoice date).

I agree with our general sales and delivery terms and with the arrangement as stated on this form.

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CONTACT

Holland Pharma
Bosberg 41
7271 LE Borculo
+31 (0)545 25 10 50
info@hollandpharma.nl

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