DUOPHARMA SINGAPORE PTE.
LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
EXTERNAL
CREATE CHANGE DELETE
Instructions and Notes:
1. The form must be filled in completely. Company reserves the right to request for additional information
2. The applicant is responsible to update the information as and when required. E.g.: Changes in the store address, Poison
License Holder, email, contact number and etc.
3. Separate forms must be completed for each Company.
4. All application forms must enclose with latest ACRA (3 months) & relevant license for submission.
Name of Business / Company:
Business Reg No.: Years in
Business:
Street Name:
Business Address
(Office): Blk /Unit No.
Postal Code:
Tel No: Fax No:
Email Add:
Clinic Name:
Delivery Address: Street Name:
(If different from
Business Address) Blk /Unit No.
Postal Code:
Tel No: Fax No:
Email Add:
Key Contact Person:
Tel No.: Fax No:
Email:
Business Operation hours:
Finance Contact Person:
Tel No.:
Email Add:
Credit Limit for New SGD 3,000 Credit 30 Days
Application: Terms:
Specimen Company Stamps:
Specimen signature of Poison License Holder:
(Poison Holder 1) (Poison Holder 2) (Poison Holder 3)
Signature Signature Signature
Name: Name: Name:
Reg No. Reg No. Reg No.
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
EXTERNAL
Please enclose the following documents:
1. CLINIC
ACRA BIZ FILE (LATEST 3 MONTHS)
MOH CLINIC LICENSE
SINGAPORE MEDICAL COUNCIL /PRACTICISING LICENSE
2. PHARMACY
ACRA BIZ FILE (LATEST 3 MONTHS)
RETAIL PHARMACY LICENSE
3. VETERINARY CLINIC
ACRA BIZ FILE (LATEST 3 MONTHS)
AVA LICENSE
4. DENTAL CLINIC
ACRA BIZ FILE (LATEST 3 MONTHS)
MOH CLINIC LICENSE
SINGAPORE MEDICAL COUNCIL /PRACTICISING LICENSE
5. OTC WHOLESALER/CHINESE MEDICAL HALL/RETAIL
ACRA BIZ FILE (LATEST 3 MONTHS)
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EXTERNAL
Personal Data and Information Notice Consent
Duopharma is entitled to maintain and process personal data of yourself and your employees / agents /
officers / directors / contractors / contact persons / shareholders / authorized persons, including but not
limited to the name, NRIC number, correspondence address, email address, mobile number and
shareholdings details of the aforesaid persons of your company, as disclosed by you prior to or
during the course of performance of this contract for the performance of contract, marketing, legitimate
business activity, administration and economic efficiency purposes. The personal data of your employees
/ agents / officers / directors / contractors / contact persons / shareholders / authorized persons may be
disclosed and shared with other entities of Duopharma Group of Companies within and outside
Singapore for the aforesaid purposes. Your company warrants that it has complied with the Personal
Data Protection Act 2012 (PDPA) and that consents have been obtained from your employees / agents /
officers / directors / contractors/ contact persons / shareholders / authorized persons in relation to the
disclosure and processing of their personal data by Duopharma for the aforesaid purposes.
All relevant fields marked (*) are obligatory and must be completed for Duopharma Singapore Pte
Ltd. to approve the credit application between Duopharma Singapore Pte. Ltd. and the company. Failure
to provide this information may affect the performance of the contract. The information may be transmitted
to Duopharma Biotech sdn bhd and its Group of Companies for the performance of contract, marketing,
legitimate business activity, administration and economic efficiency purposes.
You have the right to request a copy of the information we hold on you and to update or correct any
inaccuracies in your information. See our Guidelines on Handling Request for Access to Personal
Data and the Subject Access Request Form published on our website www.duopharmabiotech.com for
further information on PDPA.
I have read & understood the above, and I hereby give my consent to Duopharma Singapore Pte Ltd.
_________________________
Name:
Designation:
Date:
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INTERNAL
FOR OFFICE USE
PLEASE SELECT THE RELEVANT BOXES ✘
Customer Group
10 Government Hospital 11 Chain Pharmacy 12 Retail Pharmacy 13 Private Hospital 14 GP
15 Specialist 16 Ethical Wholesaler 17 Dentist 18 Veterinary 23 Direct Marketing 26 Chinese Medical Hall
28 Dialysis Center 29 OTC Wholesaler 30 Super/Hypermarket 31 Special Outlet 33 Corporate
76 Others
Sales District
Old District Code: (Refer to Annex 1)
A01 A02 A03 A04 A05 A06 A07 A08 A09 A10 A11 A12 A13 A14
A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 A26 A27 A28
Sales District Code: ________________________________(E.g. 219004 CO-Orchard, Refer to Annex 1)
Salesman Code: (Please Select)
43000000 Rep Name: ________________________
43000002 Rep Name: ________________________
43000003 Rep Name: ________________________
43000004 Rep Name: ________________________
83000419 Rep Name: ________________________
83000312 Sales Team
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
INTERNAL
FOR OFFICE USE
FOR SALES USE ONLY
Requested By: Checked By:
<Signature> <Signature>
Title: Sales Rep Title: Customer Care
Name: Name:
Sales Rep Code: Date:
Date:
FOR DANGEROUS DRUG AND CONTROL ITEM DEPARTMENT USE
ONLY
Reviewed By: Remarks:
<Signature>
Title: Pharmacist
Name:
Date:
FOR FINANCE/HOD USE ONLY
Reviewed By: Approved By:
<Signature> <Signature>
Title: Finance Title: HOD/CM
Name: Name:
Date: Date:
FOR CUSTOMER CARE/FINANCE USE ONLY
ACCOUNT NO. CREDIT LIMIT:
Created By: Created By:
_________________ _________________
<Signature> <Signature>
Title: Customer Care Title: Finance
Name: Name:
Date: Date:
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
INTERNAL
ANNEX 1
Sales District Code (ex) Description (20 Char) Corresponding postal code Old District code
211001 MA-Boat Quay 01 1
211002 MA-Chinatown 02 1
211003 MA-Havelock Rd 03 1
211004 MA-Marina Square 04 1
211005 MA-Raffles Place 05 1
211006 MA-Suntec City 06 1
211007 MA-People's Park 02 1
212001 CBD-Anson Rd 07 2
212002 CBD-Tanjong Pagar 08 2
213001 CS-Alexandra Rd 14 3
213002 CS-Tiong Bahru 15 3
213003 CS-Queenstown 14 3
214001 SK-Keppel 09 4
214002 SK-Mount Faber 10 4
214003 SK-Sentosa 09 4
214004 SK-Telok Blangah 09 4
214005 SK-Harbourfront 10 4
215001 SW-Buona Vista 11 5
215002 SW-Dover 12 5
215003 SW-Pasir Panjang 13 5
215004 SW-West Coast 12 5
215005 SW-Clementi 12 5
216001 CH-City Hall 17 6
216002 CH-High Street 17 6
216003 CH-North Bridge Rd 17 6
217001 BR-Beach Rd 18 7
217002 BR-Bencoolen Rd 19 7
217003 BR-Bugis 18 7
217004 BR-Rochor 18 7
218001 CLI-Little India 20 8
218002 CLI-Farrer Park 21 8
218003 CLI-Lavender 20 8
219001 CO-Cairnhill 22 9
219002 CO-Killiney 23 9
219003 CO-Leonie Hill 23 9
219004 CO-Orchard 23 9
219005 CO-Oxley 23 9
219006 CO-River Valley 23 9
219007 CO-Mount Sophia 22 9
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
INTERNAL
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
Sales District Code (ex) Description (20 Char) Corresponding postal code Old District code
21A001 CT-Balmoral 24 10
21A002 CT-Bukit Timah 25 10
21A003 CT-Grange Rd 26 10
21A004 CT-Holland 27 10
21A005 CT-Orchard Boulevard 24 10
21A006 CT-Tanglin Rd 24 10
21B001 CN-Chancery 28 11
21B002 CN-Bukit Timah 29 11
21B003 CN-Dunearn Rd 30 11
21B004 CN-Newton 30 11
21B005 CN-Novena 30 11
21B006 CN-Thomson 30 11
21C001 CTP-Balestier 31 12
21C002 CTP-Moulmein 32 12
21C003 CTP-Serangoon 33 12
21C004 CTP-Toa Payoh 31 12
21D001 CE-Potong Pasir 34 13
21D002 CE-Macpherson 35 13
21D003 CE-Braddell 36 13
21E001 CEE-Eunos 38 14
21E002 CEE-Geylang 39 14
21E003 CEE-Kembangan 40 14
21E004 CEE-Paya Lebar 41 14
21E005 CEE-Sims 38 14
21E006 CEE-Ubi 40 14
21F001 ECK-Katong 42 15
21F002 ECK-Marine Parade 43 15
21F003 ECK-Siglap 44 15
21F004 ECK-Tanjong Rhu 45 15
21F005 ECK-Joo Chiat 42 15
21G001 UEC-Bayshore 46 16
21G002 UEC-Bedok 47 16
21G003 UEC-Chai Chee 48 16
21H001 FEC-Changi 49 17
21H002 FEC-Loyang 50 17
21H003 FEC-Flora 81 17
21I001 FET-Pasir Ris 51 18
21I002 FET-Simei 52 18
21I003 FET-Tampines 52 18
21J001 NEH-Hougang 53 19
21J002 NEH-Punggol 54 19
21J003 NEH-Sengkang 82 19
21J004 NEH-SerangoonGardens 55 19
21K004 AMK-Yio Chu Kang 53 19
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DUOPHARMA SINGAPORE PTE. LTD
CUSTOMER MASTER CREATION FORM DSING CMCF VER.01 10 2023
INTERNAL
Sales District Code (ex) Description (20 Char) Corresponding postal code Old District code
21K001 AMK-Ang Mo Kio 56 20
21K002 AMK-Bishan 57 20
21K003 AMK-CN-AMK-Thomson 57 20
21L001 CW-Clementi Park 58 21
21L002 CW-Upper Bukit Timah 59 21
21L003 CW-Ulu Pandan 59 21
21M001 FWJ-Boon Lay 60 22
21M002 FWJ-Jurong 61 22
21M003 FWJ-Tuas 62 22
21N001 NW-Bukit Batok 65 23
21N002 NW-Choa Chu Kang 66 23
21N003 NW-Hillview Avenue 67 23
21N004 NW-Dairy Farm 68 23
21N005 NW-Bukit Panjang 67 23
21O001 FNW-Lim Chu Kang 69 24
21O002 FNW-Sungei Gedong 70 24
21O003 FNW-Tengah 71 24
21P001 FN-Admiralty 72 25
21P002 FN-Woodlands 73 25
21P003 FN-Kranji 73 25
21Q001 N-Upper Thomson 77 26
21Q002 N-Springleaf 78 26
21R001 FNY-Sembawang 75 27
21R002 FNY-Yishun 76 27
21S001 NES-Seletar 79 28
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