Business Registered Name

Company Registration Number

VAT Registration Number

Industry/ Nature of business

Telephone

Website

Authorised Representative 1

Authorised Representative 1 ID Number

Authorised Representative 1 Email Address

Authorised Representative 2

Authorised Representative 2 ID Number

Authorised Representative 2 Email Address

Billing Address Line 1

Billing Address Line 2

Billing Address Suburb

Billing Address City

Billing Address Postal Code

Billing Address Country

Postal Address Line 1

Postal Address Line 2

Postal Address Suburb

Postal Address City

Postal Address Postal Code

Postal Address Country

Upload the relevant documents (please note they need to be located in the same folder in order to upload multiple documents):</p> <ul> <li>Certified ID documents of the representatives</li> <li>Copy of any Valid Trade certificates (such as HPCSA certificates) for health professionals</li> <li>CIPC company registration certificates for health shops</li> </ul> <p>

I am a legal representative of the business listed above and agree to the terms and conditions.