Non-dispensing declaration

Non-dispensing declarationDSV Contract Logistics (Pty) Ltd 1 Meadowview Lane Meadowview Business Park Linbro Park Sandton Telephone: +27 (0)10 248 0000 www.dsv.com/en-za/ Declaration by Medical Practitioners As a non-dispensing Medical Practitioner, DSV Contract Logistics is licensed to supply you with medication for administration use only, as dictated by the Medicine and Related Substances Act and the Pharmacy Act. Please, therefore, complete the written declaration below. Your account application will remain pending until DSV Contract Logistics is in receipt of the requisite declaration. Declaration: I, _______________________________________________, a Medical Practitioner registered with the Health Profession Council of South Africa (HPCSA), Registration Number, ___________________________, hereby confirm that medication purchased from DSV Contract Logistics will be used for the purposes of administering it in accordance with my scope of practice as regulated by the Medicines. Signed:_______________________________Date:_____________________ Directors: AE Diack, N Govender, R Govender, SP Ndlela (non-exec) DSV Contract Logistics (Pty) Ltd • Reg. No. 1996/002517/07 • VAT No. 4830158897 All business undertaken in terms of our standard trading conditions. Copy available on application.