Individual Application First Name Middle Name Last Name Address Tel Email Authorize ProMed Pharmacy to sign for my registered letters Authorize ProMed Pharmacy to sign for my Courier and Parcels Other Names Using This Box Other Instructions We agree to the terms and condition set on reverse By: Title Initials Date Send Business Application Name of Firm or Business Business Address Name and Title of Chief Executive Tel Email Authorize ProMed Pharmacy to sign for my registered letters Authorize ProMed Pharmacy to sign for my Courier and Parcels Other Names Using This Box Other Instructions We agree to the terms and condition set on reverse By: Title Initials Date Send
