Pharmaceutical Request Form (RFQ)

1. Requester Information

(Fields to identify the company or individual submitting the request.)

* Company Name

* Requester’s Full Name

Job Title / Position

* Email Address

* Phone Number

Company Website (if applicable)

Company Address

City / State / Country

Type of Business

2. Product Request Details

(Fields to specify the pharmaceutical product required.)

* Product Name / Molecule

Generic or Biosimilar Name (if applicable)

Brand Name (if applicable)

* Dosage Strength

Formulation

Presentation / Packaging Format (e.g., 10 vials per box, 30 tablets per blister pack, etc.)

Preferred Manufacturer / Country of Origin (if applicable)

3. Quantity & Shipping Preferences

(Fields to define the quantity and logistics.)

* Required Quantity (Units / Packs / Boxes)

Incoterms Preference

Preferred Shipping Method

Delivery Address (if different from company address)

Special Handling Requirements (e.g., Cold Chain, Hazardous, Controlled Substance, etc.)

4. Additional Requirements & Documentation

(Fields to capture special requests or required documentation.)

Additional Notes / Special Instructions

Excel Type Files

5. Submission & Verification

Consent & Agreement

"I confirm that the information provided is accurate, and I agree to the terms and conditions of DistribuidoraFarmacéutico Pan Americana SA de CV."