Institution
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Account
Institution
Contact
Bank
Institution Name
Please enter institution name
User name
Please choose username
Email
Please enter email
Password
Please enter password
Re Password
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Add Institution Info
Street
Please enter street
Address
Please enter address
Postal Code
Please enter postal code
City
Please enter city name
Country
Select Country
Kenya
Rwanda
Tanzania
Uganda
Please select country name
Medical Field
Select Medical Field
Dental Service
Hospital ( In and Out-Patient )
Medical Service ( Out-Patient only )
Optical Service
Pharmacy
Please select medical field
Practicing Cert. No.
Please enter practicing certificate number
TIN
Please enter TIN (Tax Identification Number)
Email2
Please enter email (Optional for payment confirmations)
Back to Account
Add Contact Info
Title
Select Title
Dr.
Prof.
Mr.
Mrs.
Ms.
Please select title
First Name
Please enter first name
Last Name
Please enter last name
Designation
Please enter designation
Telephone
Please enter telephone
Mobile
Please enter mobile
Back to Institution
Add Bank Info
Bank Name
Please enter bank name
Bank Code
Please enter bank code
Bank Branch
Please enter bank branch
Branch Code
Please enter bank branch code
Account Name
Please enter bank account name
Account Number
Please enter bank account number
I accept the
Terms & Conditions
Please accept terms and condions.
Back to Contact
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