Mico Wholesale - Registration

Complete registration for healthcare facilities in Malaysia

Healthcare Facility Information

Type of Healthcare Facility *

Healthcare Facility Name *

Healthcare Facility Address *

Healthcare Facility Postcode *

Healthcare Facility City *

Healthcare Facility State/Province *

Healthcare Facility Country *

Applicant Information

Applicant First Name *

Applicant Last Name *

Applicant Position *

Telephone Number *

Fax Number

Email Address *

Details *

Identification Number *

Document Uploads

Annual Practicing Certificate 1 * Accepted formats: PDF, JPG, JPEG, PNG (Max: 2MB)

Annual Practicing Certificate 2 Accepted formats: PDF, JPG, JPEG, PNG (Max: 2MB)

Identification Card Copy - Front * Accepted formats: PDF, JPG, JPEG, PNG (Max: 2MB)

Identification Card Copy - Back * Accepted formats: PDF, JPG, JPEG, PNG (Max: 2MB)

SSM Company Profile/Borang B * Accepted formats: PDF, JPG, JPEG, PNG (Max: 2MB)

I agree to the Terms & Conditions *

Your information is secure and will be processed confidentially