Government Institution

Address

Name of Institution

Country

Postal Address

E-mail address

Telephone

Is the Institution recognized by the Government Authority that oversees provision of Health or Medical Services in your County/Area? (Attach supporting documents)- Uploading field. Pdf, jpeg

Physical Address

Name of Building/Nearest Shopping Centre

Street name / Road Name

Town/City

Country

Please keep MEDS updated on any changes in authorized people at the Institution, failure to which the signatories below shall be deemed responsible for ordering and settling outstanding payments of the transactions made by your Institution

Name of the Medical Person in charge of the Institution

Qualification

Professional Registration/Licence No

Attach supporting documents) – Uploading fields.pdf, .jpeg

Name of Medical Officer (Doctor) responsible, if any

Licence/Registration No

Is he/she resident full time only available for periodic supervision

The following persons are duly authorized to order medical supplies from MEDS.

Name:

Qualifications:

Licence No:

Name:

Qualifications:

Licence No:

Name:

Qualifications:

Licence No:

The following persons are duly authorized to approve payment for the orders.

Name:

Signature: (png/jpg)

Designation/Position:

Name:

Signature: (png/jpg)

Designation/Position:

Name:

Signature: (png/jpg)

Designation/Position:

All signatories above individually undertake to be responsible for the transactions and payments upon receipt of orders.

Guarantors: The following persons are individually and severally responsible for any outstanding bills should the Institution fail to meet its official obligations.

*Name:

*Signature: (.png/jpg)

*Designation:

Name:

Signature: (.png/jpg)

Designation:

Name:

Signature: (.png/jpg)

Designation:

CHECKLISTS.

Duly completed application forms with all the relevant parts fully filled.

Certificate of registration of the medical person (s) in-charge

Attach copies of the I.D. or Passport for persons authorized to order

Payment method

Card Number * Security Code *

Expiry Date *

Type your M-pesa Number

Type Ref ID

Government institution

Address

Physical Address

CHECKLISTS.

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