Corporate Registration Form – Central Dansoman Clinic

Organisation Details

Name of Organisation *

Address *

Postal Address *

Email Address *

Phone No. *

Alternative Phone No. *

Type of Company *

Public

Private

Date of Establishment *

Estimated Staff No.

Organisation Representative Details

Full Name *

Address *

Phone No. *

Alternative Phone No. *

Email Address *

Position *

Total No. of Beneficiaries

Payment Details

Payee Full Name *

Phone *

Alternative Phone No. *

Mode of Payment *

Cash

Cheque

Mode of Bill Delivery *

Email

Pick-Up from clinic

Delivery at a fee

Organisation Name

Kindly provide a name you will want your organisation to be addressed with. This name will also be documented and used for all official purposes. *

E.g (AFD Enterprise, Mountain Peak LTD, P.D.H, Larsey Group, Sakyi Foundation)

Declaration

Your Full Name to confirm Agreement *

I, hereby declare that the information provided to Central Dansoman Clinic Limited (C.D.C) is truthful, thereby granting C.D.C the right to verify the authenticity of the above information. C.D.C shall not be held liable for any wrong information provided by the client under any circumstance.

Date of Approval