Form Pharma - ULN Network

PHARMACEUTICAL Specialty networks registration

Please complete the following short questionnaire:

Company Information

Company Name

Country

Contact Name

How long has your company been doing Pharmaceuticals

Time in the courier business

List any certifications related to Pharma

Certifications

Name the insurance and attach policy that you have as a pharma agent.

Time

Provide 3 references of companies you have worked with:

First Reference

Company Name

Type of Business

Contact

Country

Email

Second Reference

Company Name

Type of Business

Contact

Country

Email

Third Reference

Company Name

Type of Business

Contact

Country

Email

Acceptance

I certify that the information provided is accurate and up to date.