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Company Details

TIN / JTBTIN: [If you intend to request forex transactions for import/export of regulated products, kindly use your FIRS TIN for validation.]

Company Name:

RC Number:

Date of Incorporation:

Type of Agency: Government
Non-Governmental

Company Type:

Company Contact Information

Address:

Mailing Address:

State:

Company Phone:

Contact Phone:

Company Email:

Contact Email:

Applicant Information

Representative First Name:

Representative Middle Name:

Representative Last Name:

Password:

Confirmation Password:

Applicant Documentation

Certificate Of Incorporation: [PDF]

Pharmacist's License to Practise or Receipt of Payment for Renewal [Drug Only]: [PDF]

Current Premises License [Drug Only]: [PDF]

Pharmacist's License to Practise or Receipt of Payment for Renewal Expiry Date:

Current Premises License Expiry Date:

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