Online Application Form

You must be a registered business or medical professional to apply for an account.

IF NOT, please visit your local pharmacy and ask for their selection of NamPharm products.

Back to Home

PLEASE NOTE BEFORE COMPLETING YOUR APPLICATION:

NamPharm offers a comprehensive range of services, including the provision of pharmaceutical products. This includes scheduled medicines, which are subject to strict regulations. To comply with these regulatory requirements, we must list all prospective clients in our system. This helps ensure that clients are legally entitled to purchase scheduled products.
Please complete ALL relevant sections as thoroughly as possible.
Please attach copies of all required certificates with this application to ensure it is processed as specified.
Successfully submitting your application does not guarantee approval, but it will aid in the processing of your application.

General Business Information

Owner Information

Full Name and Surname of Owner / Main Representative*

Please enter full name

Telephone Number*

Please enter your phone number

Cell Phone Number*

Please enter your cell phone number

Fax

Invalid Input

E-Mail Address*

Please enter a valid email address.

Married Status*

Married
Single Invalid Input

Marriage Contract Status*

In Community of Property
Out of Community of Property Invalid Input

Is there more than one owner?*

Yes
No Invalid Input

Owner 2 Information

Full Name and Surname

Please enter full name

E-Mail Address

Please enter a valid email address.

Telephone Number

Please enter your phone number

Cell Phone Number

Please enter your cell phone number

Fax

Invalid Input

Owner 3 Information

Full Name and Surname

Please enter full name

E-Mail Address

Please enter a valid email address.

Telephone Number

Please enter your phone number

Cell Phone Number

Please enter your cell phone number

Fax

Invalid Input

If there are more than three owners, please attach information on a separate sheet in the space provided in the upload section.

Customer and Billing Information

Registered Business Name*

Please enter the Name by which you are registered.

Postal Address*

Please enter postal address.

Delivery Address*

Please enter the physical address.

E-mail:*

Invalid Input

Date of Incorporation

Invalid Input

Telephone Number*

Please enter your phone number

Cell Phone Number*

Please enter your cell phone number

Fax

Invalid Input

Email Address for Statements*

Please enter a valid email address.

VAT Number

Invalid Input

Names of Directors / Partners / Members

Copies of IDs will be required for upload

Name*

Invalid Input

Name

Invalid Input

Name

Invalid Input

ID Number*

Invalid Input

ID Number

Invalid Input

ID Number

Invalid Input

Bank Account Details

Bank*

Select a bank

Please specify other bank name

Invalid Input

Account Number*

Enter your account number

Branch Name*

Enter your branch name

Account Type*

Select your account type

Account Name*

Enter your account name

SWIFT Code*

Enter your SWIFT code

Accounts Department Details

Name & Surname*

Please enter designated account department's name and surname

Telephone Number*

Please enter accounts department's telephone number

Cell Phone Number*

Please enter accounts department's cell phone number

Email Address*

Please enter accounts department's email address

Buyer Details

Name & Surname*

Please enter buyer's name and surname

Telephone Number*

Please enter buyer's telephone number

Cell Phone Number*

Please enter buyer's cell phone number

Email Address*

Please enter buyer's email address

Credit Application & References

Do you wish to have a Credit Account with NamPharm?*

Yes No Invalid Input

Please Note: You need to provide three references and three wholesaler accounts to confirm your eligibility

Provide 3 Wholesaler Accounts*

Please enter wholesaler names.

Provide 3 Trade / Credit References*

Please enter trade references

Applicable Downloads

The following documents will be required of you to download, complete, and sign.

Uploads are done in the following section.

Your signature is required

Please download, complete, and upload the Applicant Signatory in the next section for your credit evaluation.

Nampharm Terms & Conditions

Please download our Terms & Conditions, complete and sign the form, and upload it in the next section.

Application Surety

Please download the application's surety, complete and sign the form, and upload it in the next section.

Additional Surety

If the person signing surety is married “In Community of Property” additional surety must be signed by both parties.

Please download, complete, and upload the Nampharm Additional Surety Form and submit it in the next section for your credit evaluation.

Signature of Responsible Doctor, Pharmacist, Nurse

Please download, complete and sign the form, and upload it in the next section.

Emergency Care Service(Ambulance-Services)

Please download, complete and sign the form, and upload it in the next section.

Upload Area

Please make sure that all required documents are uploaded to complete your application

Permit 31(1) NMRC - Where applicable
Company Registration Documents/Founding Statement
Bank Confirmation Letter
IDs of all Directors/Partners/Members/Owners
Marriage Certificate of Owner / Person Signing Surety
VAT Registration Certificate
Emergency Service - please complete and submit Emergency Care Service Provider Confirmation of Responisble Doctor Affiliate Form
Registered Certificate of the Medical/Dental/Pharmacy Board or Council of Namibia (HPCNA) + Maintenance
Ministry of Health and Social Services Certificate

Click select to browse your device for the requested document.
Allowed extensions: .pdf, .doc, .docx, .odt, .jpg, .jpeg, .png

Permit 31(1) NMRC

Invalid Input

Company Registration Documents/Founding Statement

Invalid Input

Bank Confirmation Letter*

Invalid Input

IDs of Directors/Partners/Members/Owners*

Invalid Input

Marriage Certificate of Owner / Person Signing Surety

Invalid Input

VAT Registration Certificate

Invalid Input

Registered Certificate of the Medical/Dental/Pharmacy Board or Council of Namibia (HPCNA) + Maintenance

Invalid Input

Ministry of Health and Social Services Certificate

Invalid Input

Completed Nampharm Terms & Conditions*

Invalid Input

Completed Nampharm Applicant Signatory*

Invalid Input

Completed Surety*

Invalid Input

Completed Nampharm Additional Surety

Invalid Input

Completed Signature of Responsible Doctor, Pharmacist, or Nurse

Invalid Input

Completed Emergency Care Service Providers (Ambulance-Serv)

Invalid Input

You're almost done! Please review all your information and ensure all documents are uploaded. Once you're ready, click 'Submit' to complete your application.

You must be a registered business or medical professional to apply for an account.

PLEASE NOTE BEFORE COMPLETING YOUR APPLICATION:

General Business Information

Type of Business

General Entity Information

Estimated Monthly Purchases

Owner Information

Owner 2 Information

Owner 3 Information

If there are more than three owners, please attach information on a separate sheet in the space provided in the upload section.

Customer and Billing Information

Names of Directors / Partners / Members

Bank Account Details

Accounts Department Details

Buyer Details

Credit Application & References

Applicable Downloads

The following documents will be required of you to download, complete, and sign.

Your signature is required

Nampharm Terms & Conditions

Application Surety

Additional Surety

If the person signing surety is married “In Community of Property” additional surety must be signed by both parties.

Signature of Responsible Doctor, Pharmacist, Nurse

Emergency Care Service(Ambulance-Services)

Upload Area

Please make sure that all required documents are uploaded to complete your application