Elevated Database Access Application

Business & Contact Details

This will be the information we use to identify your business and keep on file to keep in contact with you.

Name:(Required)

Business Name (Pty Ltd):(Required)

Site ID:(Required)

ABN:(Required)

Postal Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Address (If different to Postal Address):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List of Practices

Do you own multiple practices? If so, please list the number of Practices and their Site ID’s below.

Number of Practices:(Required)

Please enter a number greater than or equal to 1.

Practice ID's (BPS):(Required)

Access Purpose

If you are a Practice, please refer to the Bp Partner Network Practice Tier. The Practice Tier includes reading and writing of the Bp Database and may cover the requirements you need. If in doubt, please contact the Partnership Team to discuss your requirements further.

Please detail what functions you will be performing through Elevated Data Access and the reasons this access is required:(Required)

Signed on Behalf of the Partner

This will be the person authorised to negotiate with Bp on matters regarding Elevated Data Access. Please attach additional documentation outlining other important contacts within the business if required.

Primary Contact Name:(Required)

As the Nominated Contact, I represent and warrant that I am fully authorised to act on behalf of the Business and acknowledge that the Business has responsibility to notify Bp when there is any change to the information provided in this application. I represent and warrant that the information I have provided on behalf of the Partner is true and correct.

Title:(Required)

Primary Contact phone:(Required)

Mobile:

Primary Contact email:(Required)

This form submitted on:(Required)

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Elevated Database Access Application