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Create Account - buyer
Name of Entity
Business Registration No. (ACRA)
Business Registration No. (ACRA) File
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Do you require to purchase "Poison" items?
Yes
No
MOH License No. / VC License No.
MOH License File / VC License File
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MCR / PRN / VS No.
MCR / PRN / VS File
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Name of Person-In-Charge
Date of Birth
Designation
Select Designation
Purchaser
Doctor
Pharmacist
Finance
Business Owner
Manager
Particulars
Email Address
Contact Number
Fax No
Standard Operating Hours
Delivery Address
Block No.
Street Name
Unit Number
Postal Code
Contact Person For Ordering
Order Contact Person's Name
Email Address
Contact Number
Designation
Select Designation
Purchaser
Doctor
Pharmacist
Finance
Business Owner
Manager
Contact Person For Payment
Finance Contact Person's Name
Email Address
Contact Number
Designation
Select Designation
Purchaser
Doctor
Pharmacist
Finance
Business Owner
Manager
Credit Application
Payment Terms
30 Days
Cash On Delivery
Preferred Payment Mode
Bank Transfer (Recommended)
Cash
Cheque
Bill to Entity
Yes
No
Bill to Entity Name
Billing Address
Same as delivery address?
Yes
No
Block No.
Street Name
Unit Number
Postal Code
Company Detail
Company Structure
Select Company Structure
Limited Company
Partnership
Private Limited Company
Sole-Proprietorship
Paid-Up Capital (For companies)
Nature of Business
Select Nature of Business
General Practitioner
Specialist
Wholesale
Pharmacy
Hospital
Polyclinic
Others
Name of Sole Proprietor / Partners / Directors
By checking the below box, we confirm the above information is true, accurate and updated. We undertake to make prompt payment on all invoices due and agree to abide by your terms and conditions. Pan-Malayan reserves the right to hold delivery until payment is received on all overdue invoices. The credit facility may be withdrawn at anytime, if outstanding invoices are not promptly settled. We consent to receiving all marketing updates and promotional messages via email and all other communication channels.
We understand the above information and agree to the terms and conditions
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