Category Applied For:Name Of CompanyEmail AddressPhoneWebsiteStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweTelephone NumberName and Title of the Company RepresentativeDirect Email Address of Company RepresentativePhone NumberYear when the company was establishedNature of BusinessManufactureAuthorized AgentTraderConsulting companyOtherType of BusinessCorporate/LimitedPartnershipOtherList main line of products or services you offerHave you ever been listed on Diagnostic approved supplier list?If yes when?YesNoTRADE REFERENCESList three main customers you are presently supplying with products/services and the period you have been providing stated products/services.Reference 1Company NameContact PersonEmail AddressPhone NumberPeriod of supplyReference 2Company NameContact PersonEmail AddressPhonePeriod of supplyReference 3Company NameContact PersonEmail AddressPhonePeriod of supplySECTION 3: NOSTRO BANKING DETAILSAccount NameBank NameBranch NameAccount NumberBranch CodeZWG BANKING DETAILSAccount NameBank NameBranch NameAccount NumberBranch CodeSECTION 4: SUPPORTING DOCUMENTSThe following documents must be submitted together with the registration form: 1. Letter of introduction, 2. Company profile with at least 3 traceable trade references. 3. Certified copies of all company registration documents 4. Valid Tax Clearance 5.Supplier Registration fee proof of payment.Choose FileNo file chosenDelete uploaded fileSECTION 5: CERTIFICATIONI, the undersigned, hereby accept to Diagnostic Laboratory Suppliers Terms and Conditions and warrant that the information provided in this form is correct and in the event of any changes will notify as soon as possible. *Yes, I agree with the privacy policy and terms and conditions.NameTitle:DateSignature (Enter Full Name)NOTEBy completing this form it does not automatically mean you will be added to our Suppliers Database. There will be a review and evaluation process that must take place first.SubmitSave as Draft
