Institution Information
Proprietors Information
Directors Information
Comments

Facility Information

Registration No.:*
Facility Name:*
Registration Date:*
Facility Agent:*		Facility Type:*
District:*		Bed Capacity:
Licence Fees:*

Permanent Address and Contact Information

P.O.Box No:*		PostalCode:
Town:*		Division:
Road/Street:		PlotNo:
TelNo.:*		Mobile No.:
Email:		MFL Code:

Applicant's Information

Full Name:*		Address:
Nationality:*		ID/PassportNo.:*
Date of Birth:*		Place of Birth:
Work Permit:

Proprietor Information

Proprietor Details:*

Name:

Directors Information

Name:

Nationality:

ID/PP No.:

Comments