Client Representation Form

Upload Product List:

$$ Product Turnover in Pharmacy in the last 12 months: *

Do you Credit Out of Date Stock for your Brand?

Yes No

Please Upload Your Credit Policy:

Comments

My product is in API *

Yes No

Upload API Wholesaler Information:

Level of Ranging in API:

Full Range Most Products Some Products

My product is in Symbion: *

Yes No

Upload Symbion Wholesaler Information:

Level of Ranging in Symbion:

Full Range Most Products Some Products

My product is in this Sigma: *

Yes No

Upload Sigma Wholesaler Information:

Level of Ranging in Sigma:

Full Range Most Products Some Products

Please use additional upload forms if you have more than one Group Ranging Document.

Upload Group Information:

Please include all information regarding your Group Ranging including deals and pricing.
Be as detailed as possible please.

List Groups Your Brand/Product is ranged in. *

$$ Projected Spend for Advertising:

Upload Advertising Schedule: (If Available):

Comments Regarding Advertising:

Services Required:

states: *

NSW QLD ACT VIC WA NT TAS SANational

In2Pharma Services Required:

Additional Services:

Warehousing Group Representation Wholesale Representation Chemist Warehouse & Priceline Representation

Other

Additional Comments:

Once you have submitted this form it will be sent to our staff for processing. We will get back to you as soon as possible. Thank you for taking the time to fill out this form.

Any additional documentation :