THE MAKUPA HOSPITAL
APPLICATION FOR CREDIT FACILITY
FORM
To apply for credit facility, fill in the form and send us via email, post or hand delivery.
A. INDIVIDUAL DEPOSIT
TICK WHERE APPLICABLE
Out / In Patient 10,000.00
( )
B. FAMILY
Out / In Patient 20,000.00 (
)
C. COMPANY / GROUP
5 – 20 PEOPLE 50,000.00 (
)
D. COMPANY / GROUP
21 – 40 PEOPLE 100,000.00 (
)
E. COMPANY / GROUP
OVER 41 PEOPLE 140,000.00 (
)
Find enclosed our cheque of ……………………………………………..
being deposit paid in respect of services to be rendered. I / We undertake to settle all bills on presentation by the 5th
day of the month.
Signed:........................................Position:....................................................
Client
Service No...........................................................................................
Name:..........................................................................................................
ID
No...........................................Address....................................................
Deposit Paid................................Tel............................................................
Mobile.........................................................................................................
Guarantor (Family/ Personal).........................................................................
Fax.............................................Physical
Address......................................
Email..........................................Work Number............................................
PLEASE NOTE: A Referral Letter Will Be Demanded From The Client/ Company
