Medical Clinic / Practitioner - Affiliate Account Application (14 day terms) – National Custom Compounding

The preferred affiliate sign up method is via our online form at customcompounding.com.au/partner-pharmacy-application/

Please use the following form for a manual application.

Business Information

Name of Business:

Type of Business:

ABN / ACN:

Address

Street:

City: State: Postcode:

Phone: Fax:

Email:

Account Information

Accounts Payable Contact:
Address Street: City: State: Postcode:
Email:
Phone: Fax:

Owner(s)/Director(s) Information

Name:

Name:

Address:

Address:

Phone:

Phone:

Guarantee

I/We understand that by signing I/We accept the terms and conditions of Trade as included in this application. I/We guarantee payments of all accounts for goods purchased from National Custom Compounding by the above company together with legal and/or out of pocket expenses associated with the collection of monies. I/We understand that this guarantee binds Me/Us personally.

We declare that the above information is true, correct and complete.

Name: Signature:

Position: Date:

National Custom Compounding Trading Terms

This offer sets out the trading terms that National Custom Compounding Company Limited (ABN 17 971 220 310) (National Custom Compounding) wishes to offer you (“Trading Term Agreement”), and supersedes any previous Agreement (verbal or written), arrangement, or understanding with National Custom Compounding in relation to trading terms.

National Custom Compounding Standard Terms and Conditions of Supply

All products compounded and purchased by you from National Custom Compounding will be in accordance with this Trading Term Agreement, and National Custom Compounding’s current standard terms and conditions of supply as set out on National Custom Compounding invoices and in the National Custom Compounding Account Terms & Conditions (Standard Terms). To the extent of any inconsistency between the Standard Terms and this Trading Term Agreement, the terms of this Trading Term Agreement will prevail.

Professional Service Fee

As at the date of this Agreement if you elect to agree to the Account Terms set out below National Custom Compounding will provide the corresponding terms:

Account Terms

· Account payment must be made within 7 days of statement being issued each month. Statement is issued on 1^st of the month via email.

Account payment can be made through a direct debit agreement

If payment is not received 14 days after statement issue, a late payment fee may occur.

Structure

Professional Service Fee (PSF) is provided as a discount off monthly statement.

This discount is provided to cover the cost of a professional interaction between the Patient & Medical Staff at point of collection. It is the Medical Clinic’s responsible for the provision of medicine related information to the patient when they collect their medication.

Discount is based on monthly total

Less than $1000 per month 10% Discount

Between $1000 and $2000 15% Discount

More than $2000 per month 20% Discount

Variance of Terms

National Custom Compounding can vary the terms set out in this Trading Term Agreement, in its sole discretion upon the provision of 30 days notice to you if National Custom Compounding considers there has been a material adverse change to National Custom Compounding’s margins under this Trading Term Agreement.

I agree to the above & below terms and conditions

Date: ..........................................

Signature: .............................................................................

Authorised Name: ................................................................................

Authorised Position ................................................................................

Once this form has been completed please email the completed document to admin@customcompounding.com.au

Terms & Conditions; Visit customcompounding.com.au/terms-conditions/