MODERN MEDICINES AND MEDICAL DEVICES

GENERAL INFORMATION ACCOUNT

User name*

*USER IN USE

Password*

Confirm Password*

* MISMATCH

Email*

* INVALID MAIL

Confirm email*

* MISMATCH

ID type and number*

Identification No.*

First name*

Last name*

Phone*

Modible phone*

MODERN MEDICINES

Geographic location*

Full address (including town, country and all details)*

Postal code*

Company code*

Full address (including town, country and all details)

Phone

Fax number

Email 1

Email 2

Web site

Power of Attonery duly authenticated and identified with the Registration Number Tax Information (TAX) of the company or consortium, awarded to the applicant, which proves it to perform all necessary procedures to Health Registry*

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Fiscal Information Registry (TAX)*

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Scanned ID*

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Scanned signature*

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