Business Partnership Application
afyamiahealth.carrd.co
Company Name
*
Contact Email
*
example@example.com
Company Contact Name
*
First Name
Last Name
Contact Position (Title)
*
Owner - CEO - COO
Contact Phone Number
*
-
Area Code
Phone Number
What counties do you operate in? (Select All That Apply)
*
1. Mombasa
2. Kwale
3. Kilifi
4. Tana River
5. Lamu
6. Taita/Taveta
7. Garissa
8. Wajir
9. Mandera
10. Marsabit
11. Isiolo
12. Meru
13. Tharaka-Nithi
14. Embu
15. Kitui
16. Machakos
17. Makueni
18. Nyandarua
19. Nyeri
20. Kirinyaga
21. Murang'a
22. Kiambu
23. Turkana
24. West Pokot
25. Samburu
26. Trans Nzoia
27. Uasin Gishu
28. Elgeyo/Marakwet
29. Nandi
30. Baringo
31. Laikipia
32. Nakuru
33. Narok
34. Kajiado
35. Kericho
36. Bomet
37. Kakamega
38. Vihiga
39. Bungoma
40. Busia
41. Siaya
42. Kisumu
43. Homa Bay
44. Migori
45. Kisii
46. Nyamira
47. Nairobi City
What counties do you supply your products and services? (Select All That Apply)
*
1. Mombasa
2. Kwale
3. Kilifi
4. Tana River
5. Lamu
6. Taita/Taveta
7. Garissa
8. Wajir
9. Mandera
10. Marsabit
11. Isiolo
12. Meru
13. Tharaka-Nithi
14. Embu
15. Kitui
16. Machakos
17. Makueni
18. Nyandarua
19. Nyeri
20. Kirinyaga
21. Murang'a
22. Kiambu
23. Turkana
24. West Pokot
25. Samburu
26. Trans Nzoia
27. Uasin Gishu
28. Elgeyo/Marakwet
29. Nandi
30. Baringo
31. Laikipia
32. Nakuru
33. Narok
34. Kajiado
35. Kericho
36. Bomet
37. Kakamega
38. Vihiga
39. Bungoma
40. Busia
41. Siaya
42. Kisumu
43. Homa Bay
44. Migori
45. Kisii
46. Nyamira
47. Nairobi City
How long has the company being in healthcare industry?
*
Less than 2 years
2-4 Years
4-8 years
More than 8 years
Other
What services do you currently provide? (Select All That Apply)
*
Mental health care
Dental care
Laboratory and diagnostic care
Substance abuse treatment
Preventative care
Physical and occupational therapy
Nutritional support
Pharmaceutical care
Transportation
Prenatal care
List the available services in your facility
*
How soon would you be able to execute a partnership?
-
Month
-
Day
Year
Date
Notes:
Submit
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