Application Process - L'Etang's Wholesale Chemists

Keeping your Business Healthy - Find out what L'Etang's can do for your business

Med Expo 2009

The 2009 L'Etang's Med Expo which took place on the 7th of June '09 at the 1 On 1 Conference Centre(Gateway Theatre of Shopping) was undoubtedly a huge success.

MaxiVit Plus

Please fill in the form below with your relevant details.
Alternatively download the PDF version of our form here. Once you have filled out the form, please fax it back to us on 031 577 8480.

A copy of the L'Etang's Wholesale Chemist Credit Claims Policy can be downloaded here.

Registered Name:	*
Trading Name:	*
Physical Address:	*
Postal Code:	*
Registered Address:	*
Telephone Numbers:	*
Fax Numbers:	*
Email Address:	*
Main Business Activity:	*
Auditor's Name and Address:	*
Type of Business:
Company, Close Corporation Registration Number:	*
Pharmacy Registration Number:	*
Medical Practice Number:	*
Please give details of the directors / members / partners / owners here: Please include each members Full name, Identity Number and Residential Address.	*
Have any directors / members / partners / owners signed surety of any kind?:
If you said yes to the above, please give details:	*
Are the directors prepared to sign guarantees for purchases from L'Etang's:
Have any directors / members / partners / owners ever been declared Insolvent?:
If you said yes to the above, please give details:	*
Bankers:	*
Branch:	*
Name in which account is operated:	*
Bank Account Number:	*
Name of Contact Person in respect of Payments:	*
Date Business Established?:	*
Is this a new business?:
If you said yes to the above, how long has the business been under present management?:	*
If this is a new business, then please name the previous owner?:	*
Trade References: Please include the name of the trade reference and a telephone number.	*
Are the premises?:
If not owned by customer, then please enter the name and address of the owner:	*
Please give details of other fixed property owned by the customer (not those of directors/members etc): Please give the Location, Approximate Value and Bond Balance for each property listed.	*
Please give the anticipated value of monthly purchases:	*
Vat Number:	*
Name of Contact Buyer:	*
I/We choose domicillium citandi et executandi for all purposes under this Deed of Surveyship:	*
I have read and accepted the L'Etang's Wholesale Chemist's Terms and Conditions