PLEASE FILL OUT ALL REQUIRED FIELDS

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

Customer Name *

Customer on cash basis since *

PURCHASE MADE WITHIN THE LAST 12 MONTHS

Purchase Date*

Invoice No. *

Amount(in ₱) *

Date Paid *

Amount Paid(in ₱) *

AVG Per Month(in ₱) *

Total Amount (in ₱) *

Companies/distributors with whom you do business on credit at present and which you authorize us to do credit checking.

Name / Designation *

Address *

No. of years *

Credit Limit (in ₱)*

Credit Term (days)*

Ave. Mo. Purchase (in ₱)*

Contact Person *

Tel No. *

Property type *

Description / Location *

Market Value (in ₱)*

If Mortgaged, To Whom *

Desired Credit limit (in ₱) *

Desired Credit term *

Business Name *

Authorized Representative *