Vendor Registration Form - KDKS Members (Doctors)

1. Vendor Information
Instructions:

- Complete all required fields (*).

- Ensure the information provided is accurate and up-to-date.

- Upload the necessary supporting documents.

- Submit the form after all information is correctly filled out.
1. Company Name:*
2. Full Name of Company Representative:*
3. Position:*
4. Phone Number:*
5. Email Address:*
6. Company Address:*
7. Company Registration Number:*

2. Product/Service Information
1. Type of Product/Service Offered:*

ProductService
2. Brief Description of Product/Service:*
3. Estimated Price:*
4. Minimum Order Quantity:*
5. Delivery Time:*
6. Product/Service Images:*

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3. Payment Information
1. Bank Name:*
2. Bank Account Number:*
3. Account Holder Name:*

4. Agreement and Confirmation
I agree to the Terms & Conditions set by KDKS:*

Yes, I agree
Digital Signature (Full Name):*

5. Attachments (Optional)
1. Company Registration Certificate:

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2. Halal Certificate (if applicable):

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3. Other Relevant Certificates:

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6. Additional Information (For KDKS Members - Doctors)
1. Doctor Cooperative Membership Number:*
2. Medical Specialty:*
3. Clinic/Hospital Location:*
Please proceed with the vendor registration payment
Should be Empty: