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)

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 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:

Yes
No

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):

Yes
No

PEP/Sanctions screening completed:

Yes
No

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

Date Date of signing Secure

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

Section 1 – Buyer Organisation Information

Section 2 – Licensing & Regulatory Status

Section 3 – Intended Use & Products

Section 4 – Quality, Storage & Traceability

Section 5 – Ownership & AML/KYC

Your signature