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Customer Registration Form 2023 - Industry Med
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* Indicates required question
Email
*
Your email
Your Company Name:
*
Your answer
Company Physical Address:
*
Your answer
KEY CONTACTS / RELATIONSHIPS
Details of your authorised Company personnel
Will you be your company's key contact?
*
This person will be our key client relationship.
Yes
No (please provide details in the next question)
Please list authorised key contact(s) (Name, position, phone, email)
*
Who has the authority to request and act on behalf of your company (including bookings etc)
Your answer
Please provide the name, phone number and email address for the authorised person(s) to receive pre-employment medical and/or drug and alcohol test results.
*
Your answer
ACCOUNTS / INVOICING
Name and email of key accounts person
*
Who should we contact for any invoice or account queries?
Your answer
Will you require your own
company vendor form
to be completed by us prior to invoicing for services
Yes
No
Not sure - will need to check and advise later
Clear selection
Will you provide company
Purchase Order Number(s)
for services (for reference on our invoices)
No
Yes
Not sure - will need to check and advise you later
Clear selection
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