Chemsave Chemist
Application Form

Note: Every field is compulsory. No field can be left blank. For fields that do not apply, simply enter "N/A".

Pharmacy Details

Note: These details (excluding your ABN) will be included on the chemsave.com.au website and will be viewed by the general public. Do not include any details that you don’t want to be included on this website.

Name:
Physical Street Address:
Suburb:
State:
Postcode:
Phone Number (Inc. Area Code):
Fax Number: (Inc. Area Code):
Email Address:
ABN:

Pharmacy Postal Address Details

Street Address:
Suburb:
State:
Postcode:

Proprietor Details

Name:
Home Street Address:
Suburb:
State:
Postcode:
Home Phone Number (Inc. Area Code):
Fax Number (Inc. Area Code):
Email Address:                           (Required for confidential emails)

Pharmacy Contact Details

Name:
Position:
Phone Number (Inc. Area Code):
Fax Number (Inc. Area Code):
Email Address:

Accounts Contact Details

Name:
Postal Street Address:
Suburb:
State:
Postcode:
Phone Number (Inc. Area Code):
Fax Number (Inc. Area Code):
Email Address:

Chemsave Alert SMS Notifications

Chemsave Alert SMS Notifications are used to alert the staff of Chemsave members to Chemsave Alerts that have been sent to their store by email from Chemsave Head Office. Chemsave Alerts are our main means of communication with members. Up to 3 staff members can receive SMS Notifications.

Staff Member #1:
Name:
Mobile No.:

Staff Member #2:
Name:
Mobile No.:

Staff Member #3:
Name:
Mobile No.:

Existing API Account Details
(N/A = No Account, U/A = Unknown Account Number)

API Account Number 1:
API Account Number 2:

Existing Direct Account Details
(N/A = No Account, U/A = Unknown Account Number)

Ascent Account Number:
Alphapharm Account Number:
Pharmacare Account Number:
Blackmores Account Number:
Sanofi-Aventis Account Number:
McPhersons Account Number:
Healthworld Account Number:

Current Details (Prior To Joining Chemsave)

Wholesaler:
Banner / Buying Group:
Prescription Generics Supplier/s:
OTC Generics (Private Label) Supplier/s:

Current Computer Systems (To Assist In Future Chemsave Developments)

Current Dispense System:
Current POS System:

Chemsave Membership Level (view current Membership Levels and Fees here)

Your Chosen Membership Level:

Chemsave Prescription Generics Supplier/s

Your Chosen Prescription Generics Supplier/s:

Agree To Abide By Chemsave Chemist Agreement (view current Chemsave Chemist Agreement here)

By having this box ticked and submitting this application form, I am agreeing that I am an authorised representative of the pharmacy entered on this application form, and that as an authorised representative agree that the pharmacy will abide by all terms and conditions outlined in the current Chemsave Chemist Agreement, as may vary from time to time. I also acknowledge that Chemsave Pty Ltd also agrees to abide by all terms and conditions outlined in the current Chemsave Chemist Agreement, as may vary from time to time.

Pharmacy Home
(Application Will Be Cancelled)

Chemsave Chemist Application Form

Chemsave Chemist
Application Form