Register- Medicycle

Personal Details

First Name*

Last Name*

Email*

Phone Number

Password*

Confirm-password*

Requested Role*

Buyer

Seller

Address

House/Flat Number

Street*

Address Line2

City*

Country

Postcode*

Use different address for delivery

Company Details

Limited Company Name*

Trading Company Name (if different to Limited Company Name)

Company Address

Limited Company Number (Found on Companies House)*

GPhC Registered Premises Number

ODS Code (please put n/a if not applicable)

GPhC Number (please put n/a if not applicable)

WDA(H) Number

VAT Number*

VAT Number is mandatory for Seller

Use different address for Trading Company

Upload Documents*

Bank Details

Bank Name*

Account Name*

Account Number*

Sort Code*