Pharmacist Registration - Sativite

Please complete this form

Please complete the following fields and submit your registration. If you have any questions, call us 1300 Sativa (1300 728 482)

AHPRA Registration Number*

ABN

First Name*

Last Name*

Email Address*

Phone Number*

Billing Address

Address Line 1*

Address Line 2

Suburb*

Post Code*

State*

Is your shipping address the same as your Business address?*

Yes

No

Shipping Address

Address Line 1*

Address Line 2

Suburb*

Post Code*

State*

ACKNOWLEDGEMENT OF APPLICANT OR RESPONSIBLE INDIVIDUAL(S)

Information provided may be shared with our service providers for shipping purposes only.
Sativite may share some personal information, including information provided in this document, with the applicable third-party intermediary.
You must reside in Australia.
The information in this application is correct and complete.

I understand and agree to the above

This field should be left blank

SUBMIT REGISTRATION

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I agree with the Terms. Edit this in Settings => Ajax Login Modal => Expressions tab => Registration section

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