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Medi-COP Service Provider Registration

* Denotes required field

Medical Aid Name*:
CMS Registration Number*:
Email*:
Website:
Telephone Number*:
Fax Number*:
Vat Number:
FOR THE DEBIT ORDER:
(you will receive a form via email, which must be signed and returned to us)
Bank Account No*:
Bank Account Type*:
Bank Branch No*:
Bank Account Name*: