New Hlink Medical Corporation                                            

Allson’s Inn Bldg. 201 Gen. Echavez St. Lorega, Cebu City                            

Telefax (032) 232-3269, 232-3092

 

CUSTOMER INFORMATION SHEET

 

Complete Business Name*   _____________________________________________________________

Complete Address*               _____________________________________________________________

Telephone No / Cell. No.*      _____________________________________________________________

Fax Number*                         _____________________________________________________________

E-mail (if any)                        _____________________________________________________________

 

BUSINESS INFORMATION**

Type of Business (Pls. Check) :     ( ) Single Proprietorship  ( ) Corporation

                                                      ( ) Partnership                   ______ Others

 

 

*Owners/Partners/ Incorporators              Officers Title                         Address                           Tel/Cell No.

____________________________     _______________   ________________________    ____________

____________________________     _______________   ________________________    ____________

____________________________     _______________   ________________________    ____________

 

Date of Business Started _____________________            DTI Registration No.           ________________

SEC Number                    _____________________            TIN No. of Establishment   ________________

Initial Capitalization:         _____________________

 

AUTHORIZED PERSONNEL  **

                                                                        Name                                                    Specimen Signature

Ordering of Stocks            ___________________________________           ______________________

Receiving of Stocks          ___________________________________            ______________________

Payment In Charge           ___________________________________           ______________________

Inventory In Charge          ___________________________________            ______________________

 

Monthly Sales Order   _________________                   Credit Line Desired   ______________________

Area of Coverage         _________________

 

TRADE REFERENCES **(Companies which you authorize us to do credit checking)

Name of Company                                               Address / TEL No.                                  Contact Person

____________________________      _____________________________        _____________________

____________________________      _____________________________        _____________________

____________________________      _____________________________        _____________________

 

BANK REFERENCE ** (Banks which you authorize us to do credit checking)

Bank Name                                              Address/Tel No.                            Account Number
_____________________          _______________________         _____________________

_____________________          _______________________         _____________________

_____________________          _______________________         _____________________

 

SPECIAL INSTRUCTION

REQUIRE A PURCHASE ORDER (P.O) BEFORE INVOICING? (   ) YES  (    ) NO

COLLECTION SCHEDULE: _____________________________

 

Supervisor’s Recommendation:

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

 

 

 

Documents to be submitted with this CIS. **

1. Photocopy of DTI registration or SEC

2. Photocopy of Business license and Mayors permit

3. ITR/Audited Financial Statement for the last 2 years

 

On the basis of all the information, I/We hereby authorized New Hlink Medical Corporation to investigate the reference/s

listed pertaining to our firm’s credit and financial responsibility.

It is also understood that any information that maybe later found will be a ground for cancellation

and or revocation of my credit line with the company.

 

AUTHORIZED SIGNATURE ______________________________

PRINTED NAME                     ______________________________

POSITION                                ______________________________

 

Note: Kindly have this form accomplished completely and accurately as possible

most specially those with (*) & (**) asterisk marks, before orders will be serve.