JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Become a Sheba Authorized Retailer
Thanks for expressing interest in becoming a Sheba HPV Test retailer. As part of next steps, kindly complete the questionnaire below.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What is the name of your facility?
*
Your answer
How many retail outlets do you have across Ghana?
*
Your answer
Indicate the location of your various outlets (Place an asterisk, *, beside the main outlet).
*
Your answer
Is your facility licensed by HeFRA?
*
Your answer
How many years has your facility been in operation?
*
Your answer
What is your typical order size for your regular products? Specify the unit e.g. 24 units
Your answer
Which supply model do you prefer
*
1. Cash on delivery
2. Credit supply with payment timeline within 14 days
3. End of month invoicing based on units of Sheba sold
If option 3 was selected above, indicate the name of your inventory software.
Your answer
Name of Applicant
*
Your answer
Role of Applicant
*
Your answer
Contact details of Applicant
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of yemaachi.
Report Abuse
Forms
