Account Applicant

Billing Address

Shipping Address

Pharmacist Details


Declaration of Authorised Person(s)

Product cannot be supplied until this form is completed, signed and returned with all applicable supporting documentation.

A full scanned copy of the registration, licenses and/or authorities issued by the TGA, NSWMoH or equivalent health authority is required to enable account setup and verification in accordance with legislation. Please note that an AHPRA or equivalent screenshot is not appropriate evidence of registration.

I, the Authorised Person named in the account application form, understand that:

  1. I am responsible for the order, supply and administration (as applicable) of the product,
  2. I will not permit any other person to order, receive or use the product received,
  3. I will not on-supply product outside of my legislated authority,
  4. I must provide proof of registration as and when requested by Cymra,
  5. All deliveries will be addressed to myself, the Authorised Person,
  6. Distribution of scheduled product will never be to a residential address, only the licensed / authorised premises,
  7. All invoices will be marked to my attention,
  8. I will notify Cymra of any changes related to this account,
  9. The information provided within this application is true and accurate,
  10. I have provided financial statements and trade references (where applicable), and
  11. I understand my legal obligations associated with the order and receipt of scheduled goods.