AHFOZ NUMBER * NAME OF SERVICE PROVIDER * DISCIPLINE * Anesthesiology Cardiologist Dentist Dermatologist Dietitian Haematologist Neurologist General Practioner Laboratory Ambulance Radiologist Gynaecologist Optician Physician Urologist Pathologist Ophthalmologist Pharmacy Psychiatrist Pediatrician Hospital Clinic Orthopedic Physician Other TELEPHONE/CELL * Email ADDRESS * BANK NAME * BANK ACCOUNT NUMBER(NOSTRO) * BANK ACCOUNT NUMBER(ZIG) * PRACTISING CERTIFICATE NUMBER * PRACTISING CERTIFICATE * Attach File No Choosen File (Max 2 MB) AHFOZ LETTER AND CONFIRMATION Attach File No Choosen File (Max 2 MB) TAX CLEARANCE NUMBER * TAX EXPIRY DATE * TAX CLEARANCE * Attach File No Choosen File (Max 2 MB) PREMISES LICENCE Attach File No Choosen File (Max 2 MB) HPA LICENCE Attach File No Choosen File (Max 2 MB) MCAZ PREMISES LICENCE FOR PHARMACY Attach File No Choosen File (Max 2 MB) MCAZ PERSONS LICENCE FOR PHARMACY Attach File No Choosen File (Max 2 MB) Submit
