KILIMANI HOSPITAL
SUPPLIER REGISTRATION FORM
Please fill out this form in block letters.
COMPANY DETAILS AND CONTACT INFORMATION
Company Name: ……………………………………………………………………………… Reg No.: …………….…………….
Date of Registration: ……………………………………………… KRA PIN: …….………..……………………………………
Street address: …………………………………………………………………………………………………………..……….………
Name of Building: …………….……………………….……………... Floor No.: ………… Room/Office No.: ……….
City/Town: ………………..…………. County: ………………………………….… Country: ………….……………………..
Postal Address: P.O Box …………………………Postal code: …………………… City/Town: ……………………….
Official Email Address: ……………………….…………………………………………………………….
Alternative Email Address: ……………………………………………………………………………….
Phone Number: +254 …………….….……………………… Alt Phone No.: +254 …….…………………………………
Products and services the company provides: …………………………………………………............................
…………………………………………………………………………………………………………………………………………………….
Company contact person:
Full name: ………….…………..…………………………………..……………………………… ID No.: ………………………….
Job title: ………………………………………………………………………………………
Phone Number: +254 …………….….……………………… Alt Phone No.:
Email Address: ………..……………………………………………………………..
Sales contact person: …………………………………………………….............. +254 …….……………………………….
ANTI-CORRUPTION AND ANTI-FRAUD DECLARATION:
(Insert the name of the company / supplier)
We ………………………………………………………………………… declares and guarantees that no offer, gift
or payment, consideration or benefit of any kind, which constitutes an illegal or corrupt
practice, has been or will be made to anyone by our organization or agent, either directly or
indirectly, as an inducement or reward for the sale of any products or services.
We ………………………………………………………………………… declares and guarantees that no person in
our organization has or will be involved in a fraudulent practice in any procurement proceeding.
Further we declare that we have not been convicted of corrupt or fraudulent practices.
Managing Director
Full Names: ……………………………………………………………………..……………. ID No.: ………………………………
Signature: ………………………………… Date: ………………………
Company Seal / Business Stamp
Send this form to finance@kilimanihospital.com via your official company email address. Attach your
business profile, current trade license, KRA PIN and KRA compliance certificate.