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.*