Apply To Be A Distributor Company Details Company / Legal Entity Name Registered Company Address Nature Of Operation SAHPRA Licence SAHPRA Licence Number SAMED or SALDA or MDMSA Member SAMED Member SALDA Member MDMSA Member Core Focus Percentage Woman Owned Percentage Black Owned Percentage Black Women Owned BBBEE Level Percentage Black Women Owned SA Central Supplier National Treasury CSD registration number Company point of contact going forward Contact Person Contact Email Contact Mobile Job Title Referred to by Person Referred Email Referred Mobile Referred Comment VAT registered VAT registered yes no Name and ID numbers of Entity Directors Website Link Company proof of Identity Tax clearance certificate Tax clearance certificate yes no Tax clearance number Contact Person Contact Email Contact Mobile Job Title 3 + 2 = Submit
