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Customer Enquiry Form 1B

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Please Indicate N.A. (Not applicable) in those sections that are not relevant.
Please attach additional pages if necessary (more information or insufficient space provided)

SECTION 1: COMPANY PARTICULARS

Name of Company (in block letters)

Address:

Tel No:

Fax No:

Email:

SECTION 2: CONTACT PERSON PARTICULARS

Name (Mr/Ms/Mrs/Mdm/Dr):

Designation:

Tel No:

Fax No:

Email:

SECTION 3: PRODUCT RELATED DETAILS (Please tick appropriate):

3.1 Brand Name/Strength

3.2 Benchmark (if applicable)

3.3 Product Sample

Supply by Product Owner

Supply by Beacons

3.4 Active Ingredients

3.5 Product Description

a) Product Classification	CPM	Medicinal Products	Others
	Others please specify:

b) Dosage Form	Tablet	Capsule	Cream	Gels	Liquids	Others
b) Dosage Form	Others please specify:

c) Size/Shape

d) Colour

e) Flavour

f) Coating

g) Logo/Scoreline

h) Extra Specifications

3.6 Formula	To be provided by: Product Owner	Beacons
	If provided by product owner, please furnish the details.

3.7 Manufacturing Process	To be provided by: Product Owner	Beacons
	If provided by product owner, please furnish the details.
	Process validation status: ( Yes / No)

3.8 Packaging

a) Type/Material:
b) Pack Size:

3.9 Any special requirement needed

a) Environment :
b) Equipment :
c) Others if any :

3.10 QC Testing Requirement	Raw materials
	Pharmacoepial Method If selected, proceed to A.	Non-Pharmacoepial Method If selected, proceed to B.
	A. USP BP/EP JP
	B. Validation Requirements if Non-Pharmacoepial Method is selected:
	Finished products
	Pharmacoepial If selected, proceed to A.	Non-Pharmacoepial If selected, proceed to B.
	A. USP BP/EP JP
	B. Validation Requirements if Non-Pharmacoepial Method is selected:
	Additional Testing Requirement
	Elaborate if there are any special requirement needed for testing in addition to the above mentioned:
	Stability
	Real Time OR Accelerated	Real Time AND Accelerated
	Temperature & Humidity Conditions:
	Period of Study/Time Points:

SECTION 4: RAW MATERIALS SUPPLY (Please tick appropriate):

4.1 Active Ingredients	To be provided by: Product Owner	Beacons
4.2 Excipients	To be provided by: Product Owner	Beacons
4.3 Packaging/Printing	To be provided by: Product Owner	Beacons

SECTION 5: RECOMMENDATION (for Beacons use only):

5.1 Sales

5.2 Technical

SECTION 6: ESTIMATED COST (for Beacons use only):

6.1 Finance