Customer Information Sheet

PLEASE FILL OUT ALL REQUIRED FIELDS

Fields marked with * are required,
or fill out a PDF instead and send it as an attachment to ecom1@medasia.com.ph

Customer / Establishment Name

Customer E-mail Address

BUSINESS ADDRESS

No & Street

Brgy. or Subdivision

Town / City

ZIP Code

Website URL

Telephone

Phone Number

CONTACT PERSON

Full Name

Designation

Direct Line/Local/Mobile

BUSINESS INFORMATION

Line of Business

TIN

Years in above business

Capitalization (in ₱)

Annual Sales (in ₱)

BANK REFERENCE

Bank Name

Branch

No. of Years

Ave. Daily Balance (last 6 mos)

TRADE REFERENCE

Company Name

Company Address

Contact Number

Contact Person

Designation

INSTRUCTION FOR ORDER PROCESSING

Authorized Person(s) to sign sales orders

Full Name

Designation

Authorized Person(s) to accept deliveries / sign invoices

Full Name

Designation

REQUIRED DOCUMENTS

Company Profile

Select File *pdf

Photocopy of latest Mayor's Permit

Select File *pdf

Photocopy of TIN/VAT Registration

Select File *pdf

Photocopy of Registration of Business Name

Select File *pdf

Picture of Establishment

Select File *jpg, png, jpeg

Passport Size Picture

Select File *jpg, png, jpeg

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