Business name*

Website

IBAN account number*

Bank SWIFT code*

Address of the bank's head office*

Same data as in the Basic Information

Method of delivery of the goods*Send my own courrierCourrier Pharmacopola

Same data as in the Basic Information

Please attach to the registration form:

1. WD authorization

2. Parallel import permit (if it is required)

(max. size: 5 MB, allowed file types: pdf, png, jpg, jpeg)

I agree to the general terms and conditions*