Altron HealthTech Licence & Services Agreement

Date	Practice	Dealer	Licence Type	Submitted By	Status	Actions
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Practice & Channel Partner Information

Marketing & Products Information

Payment & Acceptance Information

Channel Partner: *

Agreement: *

Licence: *

PRACTICE INFORMATION

Full name of owner(s): *
Practice's Trading Name:
Practice Business Model:		HPCSA No:
Company │ CC:		Effective Date:
ID No:
Practice No (13-Digits): *		VAT No:
Practice Discipline:		Dispensing No:

PRACTICE PHYSICAL ADDRESS

Suite / Block / Shop Name:
Building / Hospital Name:
Street Name:
Suburb:
Town │ City:
Province: *
Street Code:

PRACTICE CONTACT INFORMATION

Contact Person: *
Mobile No:
Designation:
Contact No:
Practice Email Address: *
Invoice and Finance: Email Address:
Communications Email Address:

DEALER INFORMATION

Dealer Name:
Email:

COMMUNICATION

By checking the box, you agree that Altron HealthTech may contact you regarding newsletters, special offers, promotional competitions, goods or services, or any other products offered by us, our affiliates or our partners. You may opt out of receiving such information by sending an email to healthtech.admin@altron.com

I opt in to receive marketing material from Altron HealthTech (please tick)

PRODUCT / SERVICES SELECTION

Billing Software (PMA):
Switching Software:
Conversion Fee required?	Yes, include Conversion Fee	Training required?	Yes, include Training Fee

ADDITIONAL PRODUCTS / SERVICES

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PRICING SCHEDULE

DESCRIPTION	QTY	UNIT COST	ONCE-OFF	MONTHLY

Sub Total
VAT (15%)
Total Payment Due

METHOD OF PAYMENT

MARK with “X”	EFT: Once-Off Fee – The User/Bureau agrees to do an EFT of once-off fees on the agreed date.
	Debit Order: Once-Off Fee – The User/Bureau authorises Altron HealthTech to debit the Bank Account. The first deduction is to include the once-off fees payable on:
	Debit Order: Monthly Premiums – The User/Bureau hereby authorises Altron HealthTech to issue and deliver payment instructions to your banker for collection against my/our abovementioned account on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the pricing schedule attached hereto or as agreed upon for annual increases. (A copy of the original, stamped letter from the bank, not older than 3 months from date of submission, confirming the bank account details must be enclosed).

Bank:		Branch Code:
Account Type:		Account No:
Account Name:
Special Instructions:

For Existing Clients only: In the event that the practice is an existing client of Altron HealthTech, all existing fees and billing arrangements shall remain unchanged. Any newly selected or additional Services will be incorporated into the clients current debit order mandate and billed together with the clients existing monthly fees. For the avoidance of doubt, the addition of such Services shall not amend or alter any other terms of this Agreement unless otherwise agreed in writing by all Parties.

MANDATE: I / We acknowledge that all payment instructions issued by Altron HealthTech will be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally. I/We give you the authority to update my debit order instruction. CANCELLATION: I / we agree that although this authority and mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I / we also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to Altron HealthTech. ASSIGNMENT: I / We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party.

✍ Please sign all applicable signature fields below before clicking Save Agreement.

ACCEPTANCE OF AGREEMENT

Authorised signatory/ies on behalf of the USER by (full name/s) who hereby warrants his/her/their authority and confirm/s that he/she/they has/have read the Terms and Conditions as updated from time to time and as published on Altron HealthTech's website found at www.altronhealthtech.com, understand/s them and agree/s to be bound by them. This Agreement shall commence on the Signature Date and shall remain in force indefinitely unless terminated by either Party in accordance with the Terms and Conditions. It is further agreed that the latest agreement signed by the Parties supersedes and replaces all other agreements (whether written, implied and oral) and shall be the sole governing agreement between the Parties.

Signature 1:

Clear

Designation:

Full Name:

Date:

Signature 2:

Clear

Designation:

Full Name:

Date:

Dealer / Bureau:

Clear

Full Name:

Designation:

Date:

Bureau Full Name:
Full name of owner(s):
Bureau's Trading Name:
Bureau Business Model:
Company / CC:
ID No:
Bureau Email Address:

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