Customer Data Updating Form

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the of Officer

Personal Details

Name of Applicant *

Position in the facility

Telephone Contact

Email *

Signature

Clear Signature

Facility Details

Name of Facility *

WhatsApp Number *

Nearest Landmark

Office Telephone *

Country

TIN NUMBER *

District *

Official Email Address *

County *

Website / URL

Town/City *

Do You Have a Certificate of Registration/Trading License*

Sub-County *

Certificate of Registration/Trading License*

Drag & Drop Files, Choose Files to Upload

Type Of Facility

type of facility

Ministry
Animal Clinic
Medical Centre
Health Centre IV
Training Institute
District Health Office
Health Coordination Office
Research Institution

type of facility

Project
Sick Bay
Drug Shop
Business Entity
Health Centre II
Health Centre IV
Specialized Clinic

type of facility (copy)

NGO
School
Hospital
Pharmacy
Laboratory
Nursing Home
International Health Office

Items/services you wish to purchase from JMS (tick all those that apply)

Pharmaceuticals 
Medical Equipment
Laboratory Supplies
Surgical Instruments 
Medical Sundries
Books
Others

Other Items/services you wish to purchase from JMS not listed above

Name and Qualification of the health professional with overall responsibility for Health supplies at the facility, institution or project

Name *

Qualifications *

Areas in which the healthcare supplies are to be used/distributed (If outside Uganda, please specify country)

Name of Authority licensing the provision of healthcare services

Provide details of the personnel below within your facility to facilitate follow-up on transactions and relationship management with JMS

Medical Superintendent/In Charge / Administrator / Executive director

Responsibilities : Approves orders on credit & sends out formal communication on behalf of the facilities, Staff changes , etc

Name *

Telephone contact

Email *

Position

Procurement Officer / Purchasing Officer

Responsibilities : Orders & confirms on behalf of the facility.

Name *

Telephone contact

Email *

Position

Pharmacist / Medical Officer

Responsibilities : Signs on Narcotics orders

Name *

Telephone contact

Email *

Position

Inventory Manager / Stores Manager

Responsibilities : Receives orders, reports discrepancies & is consulted on deliveries to the facility.

Name *

Telephone contact

Email *

Position

Finance Administrator / Accountant

Responsibilities : Contacted for payment follow-up

Name *

Telephone contact

Email *

Position

For Official Use Only

Facility Account No:

Date:

JMS ID No:

Attachments

Certificate of Registration
Operating License
NGO certificate
Trading License
Accreditation certificate
Annual Practising License
Letter of Introduction
Proof of payment

APPLICATION / REGISTRATION COMPLETE?

Not Completed; What is Pending *

Personnel following up for completion (JMS ID NO) *

Prepared by

Customer Solutions Officer

Date

Signature

Clear Signature

Reviwed by

Manager Customer Solutions

Date

Signature

Clear Signature

Approved by

Date

Signature

Clear Signature

Customer Data Updating Form

Personal Details

Facility Details

Type Of Facility

Name and Qualification of the health professional with overall responsibility for Health supplies at the facility, institution or project

Provide details of the personnel below within your facility to facilitate follow-up on transactions and relationship management with JMS

Medical Superintendent/In Charge / Administrator / Executive director

Procurement Officer / Purchasing Officer

Pharmacist / Medical Officer

Inventory Manager / Stores Manager

Finance Administrator / Accountant

For Official Use Only

Prepared by

Customer Solutions Officer

Reviwed by

Manager Customer Solutions

Approved by

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