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Last Name

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Store Name*

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Address 2

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City/Town

City/Town

State/County

State/County

Postcode/Zip*

Postcode/Zip*

Store Phone*

Store Phone*

Vendor type*

Vendor type*Medical Device Manufacturer Medical Device Dealer / Distributor Dental Materials Dealer

Store Legal Name*

Store Legal Name*

GST Number*

GST Number*

PAN Number*

PAN Number*

MD-42 Licence Number*

MD-42 Licence Number*

GST Certificate Upload*

GST Certificate Upload*

PAN Upload*

PAN Upload*

MD-42 Upload*

MD-42 Upload*

Bank Proof*

Bank Proof*

Compliance Declaration*

Compliance Declaration*

I agree that all orders received through DentalCall will be dispatched within the stated dispatch period and tracking details will be updated promptly.*

I agree that all orders received through DentalCall will be dispatched within the stated dispatch period and tracking details will be updated promptly.*

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