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UNAMAS
Condom Retail & Partner Form
Retailer, Pharmacy, Chemist & Distribution Outlet Registration
1. Outlet / Business Information
Is Authorized UNAMAS Distributor / Partner? *
No (Independent Retailer / Chemist)
Yes (Authorized Distributor / Partner)
Outlet / Chemist / Shop Name *
County *
Area / Town *
Physical Location / Address *
2. Contact Person / Manager Information
Contact / Manager Name *
Position / Role *
Mobile Number (UNIQUE) *
Email Address
3. Business Scope & Monthly Volumes
Business Scope / Product Lines
Years in Business
Staff Count
Est. Monthly Wellness Sales (KES)
Monthly UNAMAS Purchases (KES)
Date of First Visit / Registration
Bot Security Check *
0 + 0 = ?
Complete Bot Check to Submit