Intaleaf

Section 1 – Buyer Organisation Information

Legal Entity Name Please enter the full registered name of your organisation Secure

Trading Name (if different) Enter your trading name if different from your legal entity Secure

Registered Address Enter your full registered business address Secure

Country of Registration

UK
EU
Other

Company Registration Number Enter your official company registration number Secure

VAT/Tax ID Enter your VAT or Tax Identification Number Secure

Organisation Type

Pharmacy
Clinic / Medical Practice
Distributor / Wholesaler
Other Healthcare Entity

Regulatory Registration (if applicable)

GPhC Pharmacy
CQC Clinic
Other

Registration Number Enter your registration number (if applicable) Secure

Primary Contact Person Enter the main point of contact for this organisation Secure

Position / Role Position of the contact person Secure

Contact Email Email address for correspondence Secure

Contact Phone Main contact number Secure

Section 2 – Licensing & Regulatory Status

Do you hold valid licences/authorisations to handle controlled drugs and/or CBMPs?

WDA(H)
Controlled Drugs Licence (Schedule:)
- 2
- 3
- 4
Pharmacy Dispensing Licence
Other

Licence Issuing Authority Secure

Licence Number(s) Secure

Licence Expiry Date(s)

Day

Month

Year

Do you have an appointed Responsible Person (RP/RPi) / Superintendent Pharmacist (as applicable)?

Have you ever had a licence suspended or revoked?

Yes (please provide details)
No

Section 3 – Intended Use & Products

Products requested (tick all that apply):

Raw Flower
Oils/Extracts
CBMPs (capsules/sprays/tinctures)
Other

Intended use:

Private dispensing
Clinical trials/research
Wholesale to licensed entities
Other

Expected monthly volume (g/kg or units) (estimate if known) Secure

Delivery preferences:

Ambient (15–25°C)
Cold-chain (2–8°C)
Other

Preferred Incoterms/Courier Secure

Section 4 – Quality, Storage & Traceability

Quality Management System:

ISO/GDP compliant
Internal SOPs documented
None

Secure storage for controlled drugs:

On-site
Third-party licensed facility
No

Temperature monitoring/data-loggers in place:

Batch traceability records for MHRA audit:

Electronic system
Paper-based
None

Recall & complaints contact (24/7): Name/Phone/Email Secure

Section 5 – Ownership & AML/KYC

Directors & UBOs (names, nationalities, % ownership) Provide details for all directors and ultimate beneficial owners Secure

Any director/UBO convictions (drug/financial/regulatory)?

Yes (details)
No

AML compliance attestation (jurisdiction):

PEP/Sanctions screening completed:

Billing & invoicing contact: Secure

Accounts Email: Secure

Declaration

I/we confirm the information provided is true, complete, and accurate and that all supporting documents listed below are attached.

Signed by authorised officer of Buyer Full name of authorised signatory Secure

Position Job title or role of authorised officer Secure

Signature Type full name or upload scanned signature

Your signature

Please sign in the boundaries of the white box below

Your information is transmitted over encrypted connections and handled in line with our security policies.

Date Date of signing Secure

Required Supporting Documents (attach)

Company Incorporation Certificate

Relevant Licence(s) (e.g. WDA(H), Controlled Drugs, Pharmacy registration, CQC where applicable)

Professional or Product Liability Insurance (minimum recommended £5m for UK wholesale)

Director/UBO ID documents (passport + proof of address)

Organisational Chart (if available)

Summary of SOPs for controlled drug handling (storage/dispensing/distribution)

Privacy & lawful basis:
Intaleaf (Nompharma Ltd) will use the information you provide for onboarding, licence verification, AML/KYC checks, sanctions screening, supply-chain due-diligence and ongoing compliance monitoring. Our lawful bases are contract (Article 6(1)(b) UK GDPR) and legal obligation / legitimate interests (Articles 6(1)(c)/(f)) for regulatory checks and anti-diversion controls. We will store your data securely in the UK (or approved equivalents), retain it only as long as required for regulatory/audit purposes, and share it only with competent authorities or audited service providers where necessary (e.g., sanctions screening). See our Privacy Policy and Terms & conditions for full details and your rights (including the right to complain to the ICO). Do not upload any patient information or clinical data.
Acknowledgements (must tick all to proceed)
Authority & accuracy: I am authorised to submit this information and confirm it is true, complete and accurate.
Compliance checks: I agree to licence verification, AML/KYC and sanctions screening for onboarding and ongoing monitoring.
No patient data: I confirm no patient information or clinical data is included in the materials uploaded.
Privacy notice read: I have read the Privacy Policy and understand how my data will be used.

Welcome to IntaLeaf! 🎉
Thank you for registering as a buyer. Your reference number is # — we’re excited to have you onboard!

Who we are & how we’ll use your data
Controller: Nompharma Ltd t/a Intaleaf. We use the information you provide for onboarding, licence verification, AML/KYC checks, sanctions screening, supply-chain due diligence and ongoing compliance monitoring. See our Privacy Policy and Terms & Conditions for details and your rights. Do not upload any patient information or clinical data.