Chemsave Chemist
Application Form
 

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:                   Select ACT NSW NT QLD SA TAS VIC WA
Postcode:                  
Phone Number (Inc. Area Code):                  
Fax Number: (Inc. Area Code):                  
Email Address:                  
ABN:                  


Pharmacy Postal Address Details

Street Address:                  
Suburb:                  
State:                   Select ACT NSW NT QLD SA TAS VIC WA
Postcode:                  
 

Proprietor Details

Name:                  
Home Street Address:                  
Suburb:                  
State:                   Select ACT NSW NT QLD SA TAS VIC WA
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:                   Select ACT NSW NT QLD SA TAS VIC WA
Postcode:                 
Phone Number (Inc. Area Code):                  
Fax Number (Inc. Area Code):   
Email Address:                  
 

Existing Account Details

API Account Number 1:    
API Account Number 2:   
Ascent Account Number:     
Alphapharm Account Number:     
Pharmacare Account Number:     

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

Your Chosen Membership Level:         Select Standard Standard Plus Bronze Retail Bronze Dispensary Bronze Dispensary Standard Silver Gold

Prescription Generics Supplier/s

Your Chosen Prescription Generics Supplier/s:         Select 1st Line Ascent / 2nd Line Alphapharm 1st Line Ascent / 2nd Line Non-Alphapharm 1st Line Alphapharm One Of The Above - To Be Decided Other (Non-Compliant)

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)