Evaluation 1 – Alpro Pharmacy

Name

First Last

I/C No

Exp: 881214-XX-XXXX

Date of Birth

Age

Home Phone

Mobile Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Languages (fluent in)

Are you a registered pharmacist in Malaysia ?*

Do you have any retail experience in pharmacy setting ? If yes, please name the pharmacy that you had been working in.

Have you ever been convicted of anything other than minor traffic violations ?*

Are you involved in pending ilitigation ?

Have you or your spouse ever declared personal bankruptcy ?

Are you legally entitled to work in Malaysia ?

Will the franchise owned and operate by yourself, family members or group ?

How soon do you want to get into business ?

Amount of capital available for the business ?

Territory for which application made ? What area(s) ?*

Would you consider any other area ?

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