Business | PT Eisai Indonesia

Toll Manufacturing Request Form

Section 1 : Personal Information

Company Name*

Your Name*

Title

Your Email *

Mobile Number*

+62

Section 2 : Product Information

Product Name*

Ingredient Name

Strength/ unit dose

Product Category

Product Characteristics

Primary Packaging

5-Years Forecast Order

Year-1 *

Year-2 *

Year-3 *

Year-4 *

Year-5 *

Targeted processing Fee per unit

Targeted Launch (DD/MM/YYYY)*

IDR:*

Unit:*

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Section 3 : Additional Information

Please type other necessary information here:*

By ticking the box, I grant my consent to PT Eisai Indonesia to use my Confidential Information and Personal Data, such as Company Name, Product Name, Product Details, Person In Charge, Email and Phone Number for the purposes as stated in the Title. For the avoidance of doubt, this consent is required and subject to the applicable laws of Indonesia.