Ubrica Retail Clinical Centers Franchise Pre-qualification Form

Ustawi Biomedical Research Innovation and Industrial Centers of Africa, Inc. (UBRICA), is poised to enter the African market with a network of retail clinical centers (RCCs) with clinical diagnostic labs franchised for large-scale distribution in Africa. Ubrica Health Services Limited (UHS) will manage the RCC franchise. Please complete and submit the form below to express interest in the franchise.

Thank you.

Ubrica Health Services Clinical Centers Franchising Team

First Name
Please enter your First Name
Your answer
Last Name
Please enter your Last Name here
Your answer
Email address
Your answer
Mobile Phone Number
Your answer
Date of Birth
Please enter your Date of Birth (Month Day Year)
MM
/
DD
/
YYYY
Stree Address
Type your street address here or Post Office Box
Your answer
City
Enter your city here
Your answer
State/Province
Your answer
Country
Your answer
Comments or questions
Please feel free to ask questions and share comments regarding the franchise.
Your answer
Consent
By submitting this on-line application, you consent to UBRICA and its affiliates collecting, using and retaining your personal information as is reasonably required in the course of our evaluation of your application, including to assess your eligibility, process your application, and respond to you. For further information concerning how we collect, use and disclose personal information, you should refer to our privacy policy at http://www.ubrica.com. Furthermore, you acknowledge that the statements and information provided in this application is fully and truthfully set forth your true and accurate personal information and financial conditions as of the date hereof. You, the undersigned acknowledge and consent to the collection of additional information with respect to the information provided below. You, the undersigned consent to UBRICA and/or its agents collecting and retaining such information and conducting further investigations with respect to such information. You undersigned further consent to the updating of this information from time to time, when necessary. You acknowledge that the submission and acceptance of this application is not to be construed as an approval or future guarantee of becoming a URCC Owner and that this document does not legally obligate either party in any manner.
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of KDNC. Report Abuse - Terms of Service - Additional Terms