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Business name
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Please provide a valid business name (2-100 characters).
Business category
*
Select Business Category
Hospital
Pharmacy
Clinic
Patent
Please select your business category.
Business email
*
Please provide a valid email address.
Business phone
*
Please provide a valid phone number.
Contact Person
*
Please provide a valid contact person name (2-50 characters).
Contact Phone
*
Please provide a valid contact phone number (10-15 digits).
CAC License Number (Optional)
Please provide a valid CAC License Number.
Operating License Number (Optional)
Please provide a valid Operating License Number.
Rep ID (Optional)
State
*
Select State
Please select your state.
LGA
*
Select LGA
Please select your LGA.
Street Address
*
Please provide a valid street address (5-200 characters).
Password
*
Min 8 chars with uppercase, lowercase, number & special char
Password must be at least 8 characters with uppercase, lowercase, number, and special character.
Confirm password
*
Passwords do not match.
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