Become a Partner

Member Registration Form

Join Celyncare's growing network of pharmacies, hospitals, and health institutions. Complete all required fields — our team responds within 2–3 business days.

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👤 Personal & Business Information

First Name *

Last Name *

Email Address *

Phone Number *

Business / Organisation Name *

Membership Type *

State / Location *

Business Address *

🏛️ Registration & Licence Details

CAC Registration Number *

Licence Number

Years in Operation

Avg. Monthly Order Volume

⚠️ Pharmaceutical Distribution Requirements To be approved for pharmaceutical products, applicants must have a valid CAC registration, a premises or hospital licence, and operate as a registered business (Pharmacy, Hospital/Clinic, or Health Centre).

💊 Product Interests

Primary Products of Interest

Additional Notes or Requirements

📎 Supporting Documents

Our team will contact you to collect digital copies of your CAC Certificate, Premises / Hospital Licence, and Valid ID upon approval of this form.

Confirm Documents Available