Vendor Application Form

Vendor Application Form Instructions The Vendor Application Form and all supporting documentation (if required) must be fully completed by the vendor in order to receive Purchase Orders and Payments from Pfizer. Please type or clearly print all required information (as indicated by an asterisk *) and return to your Pfizer contact.

Company Headquarters Please provide the full company headquarters' name and address (no P.O. boxes). Name: *

Region/State/Province: *

Street: *

Postal Code: *

City: *

Country: *

Purchasing Information The below information will be used for Purchase transactions between Pfizer and your company, and will show on Purchase Orders. Please tick the below box if the Ordering Address is the same as the headquarters Address. *Note - Contact details, currency and description of goods and services purchased are still required. Ordering Address is the same as the Company headquarters Address Name: *

Contact Name: *

Street: *

Contact Phone: *

City: *

Contact E-mail: *

Region/State/Province: *

Currency: *

Postal Code: *

Please provide a description of the goods or services being purchased:*

Country: *

Enter the e-mail address and fax number where Purchase Orders should be sent. Please set up generic accounts where possible to ensure Purchase Orders are still received if a contact leaves your company or is unavailable: E-mail Address:

Fax Number:

Remittance Information The below information will be used for invoice and payment transactions between your company and Pfizer. Please tick the below box if the Remittance Address is the same as the headquarters Address. *Note - Contact details and currency are still required. Remittance Address is the same as the Company headquarters Address Name: *

Contact Name: *

Street: *

Contact Phone: *

City: *

Contact E-mail: *

Region/State/Province: *

Currency: *

Postal Code: * Country: * When payment is made, you will receive a notification with payment details. Enter the e-mail address and fax number where remittance communications should be sent. Please setup generic accounts where possible to ensure communications are still received if a contact leaves your company or is unavailable: E-mail Address:

Fax Number:

Enter the customer service contact information for handling invoice rejections and billing inquiries: Contact Name: *

Contact E-mail: *

Contact Phone: * If your company participates in an electronic document exchange solution, please provide the name of the network provider: If your company is part of the Ariba Network, please provide the ANID: For questions regarding electronic invoicing, please go to http://www.pfizer.com/b2b/suppliers/po_terms_and_conditions or contact [email protected].

Bank Details Please complete the bank details below (checking accounts only). Bank # 1

Bank # 2 (if needed)

Bank Name: *

Bank Name: *

Bank Country: *

Bank Country: *

IBAN Number: *

IBAN Number: *

Bank Routing Number (Sort Code, ABA):

Bank Routing Number (Sort Code, ABA):

Swift Code: *

Swift Code: *

Bank Account Holder Name: *

Bank Account Holder Name: *

Bank Account Number: *

Bank Account Number: *

Currency:

Currency:

Additional information needed for the bank to process payment (e.g. Bankgiro Number):

Additional information needed for the bank to process payment (e.g. Bankgiro Number):

If more than one bank was listed above, please specify the purpose of providing multiple banks:

Tax Identification Enter your VAT and all your tax information below and specify the Tax ID Type for each Tax ID. Multiple Tax IDs can be provided if applicable.

Tax ID: *

Tax ID Type: *

Tax ID:

Tax ID Type:

Tax ID:

Tax ID Type:

Tax ID:

Tax ID Type:

VAT Registration Number: *

If a Tax ID was not provided above, please provide an explanation:

Supporting Documentation Please confirm with your Pfizer contact if there are any other Supporting Documents required for the Country you are working with. If there are, please provide them to your Pfizer contact. Confirm that Supporting Documentation is being provided along with this Vendor Application Form to your Pfizer contact. (If needed) *

Certification I am authorized to sign this form on behalf of the vendor identified above and I hereby certify that the information provided is true, accurate, and complete as of this date. * I also agree to Pfizer Standard terms and conditions. * (Refer to http://www.pfizer.com/b2b/suppliers/po_terms_and_conditions) This data will be stored securely and used for processing your business relationship with Pfizer. This may involve the data being transferred to countries where there is not equivalent protection legislation.

Printed Name: *

E-mail Address: *

Signature: *

Phone Number: *

Date: * Job Title: *

Vendor Application Form Instructions The Vendor Application Form and all supporting documentation (if required) must be fully completed by the vendor in order to receive Purchase Orders and Payments from Pfizer. Please type or clearly print all required information (as indicated by an asterisk *) and return to your Pfizer contact.

Company Headquarters Please provide the full company headquarters' name and address (no P.O. boxes). Name: *

Region/State/Province: *

Street: *

Postal Code: *

City: *

Country: *

Purchasing Information The below information will be used for Purchase transactions between Pfizer and your company, and will show on Purchase Orders. Please tick the below box if the Ordering Address is the same as the headquarters Address. *Note - Contact details, currency and description of goods and services purchased are still required. Ordering Address is the same as the Company headquarters Address Name: *

Contact Name: *

Street: *

Contact Phone: *

City: *

Contact E-mail: *

Region/State/Province: *

Currency: *

Postal Code: *

Please provide a description of the goods or services being purchased:*

Country: *

Enter the e-mail address and fax number where Purchase Orders should be sent. Please set up generic accounts where possible to ensure Purchase Orders are still received if a contact leaves your company or is unavailable: E-mail Address:

Fax Number:

Remittance Information The below information will be used for invoice and payment transactions between your company and Pfizer. Please tick the below box if the Remittance Address is the same as the headquarters Address. *Note - Contact details and currency are still required. Remittance Address is the same as the Company headquarters Address Name: *

Contact Name: *

Street: *

Contact Phone: *

City: *

Contact E-mail: *

Region/State/Province: *

Currency: *

Postal Code: * Country: * When payment is made, you will receive a notification with payment details. Enter the e-mail address and fax number where remittance communications should be sent. Please setup generic accounts where possible to ensure communications are still received if a contact leaves your company or is unavailable: E-mail Address:

Fax Number:

Enter the customer service contact information for handling invoice rejections and billing inquiries: Contact Name: *

Contact E-mail: *

Contact Phone: * If your company participates in an electronic document exchange solution, please provide the name of the network provider: If your company is part of the Ariba Network, please provide the ANID: For questions regarding electronic invoicing, please go to http://www.pfizer.com/b2b/suppliers/po_terms_and_conditions or contact [email protected].

Bank Details Please complete the bank details below (checking accounts only). Bank # 1

Bank # 2 (if needed)

Bank Name: *

Bank Name: *

Bank Country: *

Bank Country: *

IBAN Number: *

IBAN Number: *

Bank Routing Number (Sort Code, ABA):

Bank Routing Number (Sort Code, ABA):

Swift Code: *

Swift Code: *

Bank Account Holder Name: *

Bank Account Holder Name: *

Bank Account Number: *

Bank Account Number: *

Currency:

Currency:

Additional information needed for the bank to process payment (e.g. Bankgiro Number):

Additional information needed for the bank to process payment (e.g. Bankgiro Number):

If more than one bank was listed above, please specify the purpose of providing multiple banks:

Tax Identification Enter your VAT and all your tax information below and specify the Tax ID Type for each Tax ID. Multiple Tax IDs can be provided if applicable.

Tax ID: *

Tax ID Type: *

Tax ID:

Tax ID Type:

Tax ID:

Tax ID Type:

Tax ID:

Tax ID Type:

VAT Registration Number: *

If a Tax ID was not provided above, please provide an explanation:

Supporting Documentation Please confirm with your Pfizer contact if there are any other Supporting Documents required for the Country you are working with. If there are, please provide them to your Pfizer contact. Confirm that Supporting Documentation is being provided along with this Vendor Application Form to your Pfizer contact. (If needed) *

Certification I am authorized to sign this form on behalf of the vendor identified above and I hereby certify that the information provided is true, accurate, and complete as of this date. * I also agree to Pfizer Standard terms and conditions. * (Refer to http://www.pfizer.com/b2b/suppliers/po_terms_and_conditions) This data will be stored securely and used for processing your business relationship with Pfizer. This may involve the data being transferred to countries where there is not equivalent protection legislation.

Printed Name: *

E-mail Address: *

Signature: *

Phone Number: *

Date: * Job Title: *