CRICE Company Registration Request Form

Privacy Notice and CPOC Responsibilities

Before continuing, you MUST read the MTS Privacy Notice: https://masoom.co.za/privacy-notice/

1. Yes, I have received and read the MTS Privacy Notice (or had it explained to me) and I have understood it. *

2. Your responsibility as Company Point of Contact (CPOC) — processing necessary for legitimate business use of the CRICE system, POPIA s11(1)(f), with consent obtained from each data subject.

Before entering or enrolling any company representative's details on the CRICE system, your company must, as set out in the MTS Privacy Notice:

Provide the MTS Privacy Notice to each representative (or have it explained to them);
Obtain that person's consent to the processing of the following specific information:
- name and date of birth;
- business email address and business contact numbers;
- identity verification against the access-card photograph at first check-in;
- digital photograph (displayed on the CRICE access card for identity verification);
- declaration of adequate Product training;
- declaration of Hepatitis B vaccination, or of declined vaccination with a company risk analysis;
- check-in and check-out records at healthcare facilities (electronic visit and attendance register);
- appointment management through CABS, including reason for visit and products sold/detailed.
Keep dated records of each consent.

I understand and accept these CPOC responsibilities on behalf of my company. *

3. Your CPOC profile — in requesting that your company be CRICE registered, and by completing this form, you agree that the information you provide is used to set up your CPOC profile, which then allows you to enrol your company's representatives, manage bookings, and receive check-in/check-out notifications.

I agree to my information being used to set up my CPOC profile for these purposes. * 4. Company logo on crice.co.za

MTS requests your permission to display your company logo on crice.co.za as a CRICE participating company. This is voluntary and may be withdrawn at any time via info@masoom.co.za.

Yes — I give permission, and will upload our logo below No — please do not display our logo

Upload your company logo (PNG or JPG, max 2 MB)

Required if you granted permission above.

5. Marketing materials from Masoom Training Solutions (your opt-in consent — POPIA s69) Yes, I consent to receiving marketing materials from Masoom Training Solutions No, I do not wish to receive marketing materials

6. Bot prevention and real-person verification — legitimate interests, s11(1)(f).
The link to this form is posted on public websites and can therefore be found and targeted by automated programs (bots). To protect this form against automated (bot) submissions and to verify that your application comes from a real person, the IP address of the device used to submit this form is recorded, together with the date and time of submission, and is kept as part of your signed consent record. It is used for no other purpose.

Yes, I understand and accept the above. *

Company Details

Company Full Name Company Registration Number VAT Number (if applicable) Company Website Products Sold — just list your top 5 products (separate using commas) Physical Address

Company Point of Contact (CPOC)

The Company Point of Contact is the person responsible for enrolling staff into CRICE training, managing bookings, and liaising with Masoom Training Solutions on behalf of the company.

First Name Surname Business Mobile Number Business Telephone (Landline) Business Email Address Date of Birth

Used only to tell apart two people with the same name, as described in the Privacy Notice.

Secondary Point of Contact (Optional)

You may nominate a secondary point of contact who will also receive check-in/check-out notifications and have full access to the CRICE system with their own login credentials. This person may act as a backup to the CPOC.

By providing another person's details below (secondary POC or reporting contact), you confirm that you have shown them the MTS Privacy Notice and that they consent to being contacted for these purposes.

Full Name Email Address Contact Number Date of Birth

Reporting Contact (Optional)

If you would like someone other than the CPOC to receive the monthly facility visit reports, please provide their details below, with their consent.

Full Name Email Address

Supporting Documents

Upload the vetting documents below (PDF, JPG or PNG, max 5 MB each) — no need to email them separately.

VERY IMPORTANT: Redact any confidential info before sending.

Company Registration Documents I do not have this document SAHPRA registration/licence, or existing formal documentation generated during normal company operations with any hospital group proving that you do business with at least one CRICE participating hospital and therefore require CRICE Access Cards (formulary listing or application, relevant correspondence, purchase order, etc.) I do not have this document Valid Tax Compliance (SARS Tax Compliance Status) I do not have this document

Declaration and Signature

By submitting this form, I confirm that all information provided is accurate and complete to the best of my knowledge, and that the acknowledgement and consent selections above reflect my own decisions. * Type your full name as your electronic confirmation I hereby consent to the above and affix my signature — sign in the box below (finger or mouse)

Draw your signature above.

Your information is sent securely over HTTPS and processed as described in the MTS Privacy Notice.