Courier Account Application Form | Clinical365

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Company Information:

Company Name(Required)

Company Registration Number (Required)

VAT Identification Number

Contact Information:

First Name(Required)

Last Name(Required)

Email(Required)

Phone Number (Required)

Business Address:

Country/Region(Required)

Address(Required)

City(Required)

Zip / Postal code(Required)

Shipping Profile:

Estimated Monthly Shipments

Service Type Needed

Domestic

International

Both Domestic and International

Temperature Control

Packaging

25600 Rye Canyon Road, Suite 102, Valencia, California, United States, CA 91355

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