Supplier Registration Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of CompanyAddress of CompanyContact Person *FirstLastEmail *Mobile NumberBRN (Business Registration Number)VAT registered numberLicensee NumberLicensee NameAddress of licenseeEmail Address of Licensee *Telephone/mobileName of Marketing Authorisation HolderContact number of Marketing Authorisation HolderName of Local Technical RegulatorContact number of Local Technical RegulatorIs the company a pharmaceutical wholesale? *NOYESPharmacist in chargeRegistration number of PharmacistContact details of Pharmacist in chargeEmail Address of Pharmacist in chargeDIRECTOR'S DETAILDirector/s of companySubmit