Apply for Medicine

Fill in your details and the quantity you need. You will get a reference number to track your application.

1 Your Details Your Details

Applicant Name

Mobile Number

A 10-digit mobile number. Updates are sent here.

2 Address Location

Block

GP / Municipality

Area / Village

Detailed Address

3 Quantity & Remarks

Quantity Required

Up to 2 available.

Additional Remarks

I confirm the details above are true and I consent to being contacted by the MLA's Office about this submission.

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