定点零售药店诚服务信用等级评定申请表.doc

定点零售药店诚信服务信用等级评定申请表 药店 名称 代码 联系人 联系电话 邮编 药店 地址 药店 区域 主城区/非主城区 药店面积 药师人数 医保定点时间 上年度考核情况 上年度违规被处理情况 上年及本年度被相关主管部门处理情况 本年度医疗保险服务及违规被处理情况 申请内容： 申请等级： 级。 申请单位（盖章）： 法定代表人（经营者）签字： 年 月 日 受理时间： 南通市市区定点零售药店营业场所平面示意图 北 ↑ 实际营业面积： 平方米。 定 点 零 售 药 店 名 称 日期 注：本图上北下南，请准确示意药店营业场所平面布局及尺寸，并详细注明实际营业面积，单位：平方米。 南通市市区定点零售药店药师情况表 定点单位名称（盖章）、代码： 序号 姓 名 性别 身份证号码 职称 职称证书号 执业证书号 填报日期： scope this document applies to all branches of the Banks personal loans (not including personal loans and fund loans). 2.2 target customers, consumer loan customers: with a focus on marketing the Government civil servants, official staff of public institutions, telecommunications, electricity, tobacco and other more efficient State-owned enterprises staff, finance, insurance, education, scientific research scope this document applies to all branches of the Banks personal loans (not including personal loans and fund loans). 2.2 target customers, consumer loan customers: with a focus on marketing the Government civil servants, official staff of public institutions, telecommunications, electricity, tobacco and other more efficient State-owned enterprises staff, finance, insurance, education, scientific research scope this document applies to all branches of the Banks personal loans (not including personal loans and fund loans). 2.2 target customers, consumer loan customers: with a focus on marketing the Government civil servants, official staff of public institutions, telecommunications, electricity, tobacco and other more efficient State-owned enterprises staff, finance, insurance, education, scientific research