Vendor Registration

Application for Registration & Account Opening

Register as an approved vendor with Gen-Wadadisa Pharmaceuticals. You can either complete the form online below, or download the PDF form to print, complete, and submit manually.

Complete Online

Fill in the registration form directly on this page and submit it electronically.

Fill Form Below ↓

Business Details

Registered Company Name *

Trading Name (if different)

Type of Business *

Nature of Business *

Company Registration Number

Date of Incorporation

VAT Number

Regulatory & Compliance Details

Please have certified copies of all current licenses and certificates ready for submission.

MCAZ / HPA Company Registration No.

Medical Practitioner HPA Practicing Certificate No.

MCAZ Dispensing License No.

License Expiry Date

Contact & Address Details

Registered Physical Address *

Delivery Address (if different)

Postal Address

Postal Code

Telephone No. *

Cellphone No.

Email Address (General) *

Key Authorized Personnel

Orders Contact Person

Orders Contact Email/Cell

Accounts/Finance Contact

Accounts/Finance Email/Cell

Banking Details

Bank Name

Branch Name

Account Name

Account Number

Directors / Partners / Members

Full Name

Residential Address

ID / Passport Number

Trade References

Company Name

Account Number

Contact Person

Telephone / Email

Supporting Documents

Attach certified copies of VAT certificate, MCAZ licenses, dispensing licenses, and any other relevant documents (PDF, DOC, JPEG, PNG — max 10MB each).

Upload Document

Declaration & Sign-Off

Authorized Signatory Name *

Capacity / Designation *

Signed At (City/Town)

I/We, the undersigned, hereby certify and warrant that the information provided above is true, accurate, and complete. I am filling this out in my authorized capacity to bind the Customer to these terms.

I confirm that all information provided is true and accurate, and I agree to the terms and conditions of trade with Gen-Wadadisa Pharmaceuticals. *