Client services order

Application

C.C.O.A

Date:

Company name:

Contact person:

Tel No:

Fax No:

Add:

Service:

D

M

q ambulance Duration from date / / to / /

D

M

q medics Duration from date / / to / /

M

D

q nurse q doctor

q mobile clinic Duration from date / / to / /

D

M

q medicine supply Duration from date / / to / /

More details:-

· Send via e-mail ( info@fmg.com.ly) or fax it to ( +21 8 214831316 )