Kenya Medical Laboratory Technicians & Technologist Board

Providers Registration Form

Instructions and Requirements

1. The application form must be completed by dully authorized person.
2. All the required documents MUST be attached in pdf format.
3. The application fee of Ksh 1,500.00 MUST be paid via LIPA Na Mpesa(Non- Refundable).

Providers /Institution Name:

Institution Type:

Facilitator Name:

Postal Address:

Phone Number:

Email Address:

County:

Constituency:

Ward:

Physical Address (Road, Street and Building):

Website:

Business Certificate:

KRA PIN:

KRA Tax Compliance:

Facilitator's CV:

I / we the undersigned verify that all the information in this form and accompanying documentation is correct and true to the best of my knowledge. I also agree to inform the Kenya Medical Laboratory Technicians and Technologists Board, about any changes or modifications made on the information given in the documents submitted.

Providers Registration Form

Instructions and Requirements

Submit Application