This website is for Australian healthcare professionals only.  
Request a Sanofi Pasteur Account
All fields are mandatory

Your details

Trading name A.C.N.
Company Name (if applicable) A.B.N.
Subsidiary/Division (if applicable) A.B.N.
If the Legal Entity is a Trust Fund, the owner of the Trust Fund MUST sign this form.
Nature of business
Date business commenced
(dd/mm/yyyy)

Contact Details

Purchasing Accounts
Contact name
Phone
Fax
Email
Same contact for Purchasing and for Accounts

Licensing Details

Doctors Full Name Prescriber No.
Pharmacist Full Name Board Regn. No.
Registered Nurse Full Name Licence Number
Wholesale Licence Licence Number
Yellow Fever Accreditation (if applicable) License Number

Postal Address

Address
State Postcode

Delivery Address

Address
State Postcode

Other delivery addresses

1 Contact Name Contact Phone
  Doctors Full Name Prescriber No.
  Address
  State Postcode
2 Contact Name Contact Phone
  Doctors Full Name Prescriber No.
  Address
  State Postcode
3 Contact Name Contact Phone
  Doctors Full Name Prescriber No.
  Address
  State Postcode

Trade References

Company Name Phone Number Account Number
1
2
3
Please note, Wholesalers, Utility Providers or Finance Institutions are not considered acceptable references.

Monthly Purchase

Estimated Monthly Purchases    $ (Credit Limit)
This is the limit that will be enforced on the account.

Signature

we Hereby :
  1. Agree to settle by the due date according to the Sanofi Pasteur Pty Limited Terms and Conditions of Sale.
  2. Agree that any change in respect of ownership, legal entity or address be notified within five (5) working days.
  3. Acknowledge that credit may be withdrawn at any time without prior notice in accordance with Sanofi Pasteur Pty Limited Terms and Conditions of Sale.
  4. Agree to provide Directors Personal Guarantees should this be required by Sanofi Pasteur Pty Limited.
  5. Agree to Sanofi Pasteur obtaining information from a credit agency that may contain confidential information.
  6. Acknowledge receipt of and accept Sanofi Pasteur Pty Limited present standard Terms and Conditions of Sale and acknowledge that the conditions may be changed unilaterally from time to time.
I agree to these terms.
You have to agree these terms to continue
Position
Name
Date
  
You can also send an application request by completing and sending back this document : Application Request form
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Last update: 22/11/2019