Company Name (required)

Select Categories (required)
—Please choose an option—ManufacturerWholesaler

Address (required)

Phone No (required)

Fax

Your Email (required)

Country Name

Company registration number and Vat number

Legal representative (required)

Do you hold an official wholesaler’s /manufacturer’s licence released by your ministry of health? (required)
—Please choose an option—YesNo

Remarks on the licence

Attach the licence

Do you work according to the rules of the GDP (good distribution practices)? (required)
—Please choose an option—YesNo

Remarks on the GDP

What products do you deal in? (required)
—Please choose an option—Registered drugsDrugs for compassionate UseFoodNon-registered drugsOther

Remarks on the products

Remarks on the lot numbers

Do you have a system for the recall of non-conforming lots? (required)
—Please choose an option—YesNo

Remarks on the lot recalls

Do you deal in products requiring temperature control? (required)
—Please choose an option—YesNo

If yes, do you guarantee conservation and transport in order not to interrupt the necessary refrigeration chain?

Remarks on the documentation

Remarks on the liability

Do you accept return of goods?(required)
—Please choose an option—YesNo

Check Details (required)
—Please choose an option—YesNo

Attach the terms of sale (required)

Remarks on the terms of sale

Remarks on the packaging

Do you confirm receipt of orders?(required)
—Please choose an option—YesNo

If yes, please specify in which way

Remarks on the price changes

Person responsible for dealing with complaints(required)

Do you have a certified Quality System?(required)
—Please choose an option—YesNo

Attach certifications

Subject

Additional remarks(required)