Request for Read Only License

A read only license contract would be sent to you for signing after submitting this form electronically.

 
 
 
 
Customer No.*
 
 
 
 
Customer Name*
 
 
 
 
Requestor’s Name*
 
 
 
 
Requestor’s Position*
 
 
 
 
Email Address*
 
 
 
 
Phone Number*
 
 
 
 
Date required for this to be actioned*
 
 
 
 
 
 
 
I/We require read only licenses at a cost of $ 1200+GST per license per year 
How many licenses would you require?*
 
 
 
 
 
 
 
Upload a copy of your current Medtech license*
 
 
 
 
 
 
 
 
 
 

Note: Go to Help/Register option on the Menu Bar and use a snipping tool to take a screenshot. If the snipping tool is not available, please do CTRL + SHIFT + Print Scrn and then paste it on a word document. Please save it on your computer and upload that file

 
I have read and accept the Privacy Policy and I am authorised to make this commitment on behalf of my organisation.*
 
 
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