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1Commercial Identity

Customer No

Customer Name

Owner Name

Legal Status

CR Number

CR Membership

Capital

Establish Date

Contract Type

Client Type

2Contact & Location

Branch

City

PO Box

Phone

Address

Mobile

Fax

3Management & Personnel

Rep Name

Rep No

Pharmacy Owner

GM Name

Acc Manager

Store Manager

4. Authorized Signatories

Authorized Person 1

Designation 1

Signature Ref 1

Authorized Person 2

Designation 2

Signature Ref 2

Authorized Person 3

Designation 3

Signature Ref 3

5. Financial Security

Insurance Exists?

Insurance Name

Company Name

Warrant Name

Warrant ID / Date

Sponsor & Date

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