Medicine Representative Registration

Full Name

Please provide your full name.

Please provide a valid email.

Mobile Number

Please provide a valid 10-digit mobile number.

Date of Birth

Please provide your date of birth.

You'll need this for password recovery.

Pharmaceutical Company

Please select a pharmaceutical company.

Profile Image (Optional)

Please provide a valid image file.

Employment ID Card *

Please upload your employment ID card.

Will be visible to doctors and admin for verification.

Employee ID *

Please provide your employee ID.

Bio (Optional)

Password

Password must be at least 8 characters.

Confirm Password

Passwords must match.

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