Free agency agreement 07

AGENCY AGREEMENT

between

Universal Healthcare Services (Pty) Ltd
(Reg. No: 2008/005871/07)
(hereafter referred to as Universal)
and

______________________________________________________________

Reg. Number / Identity Number: ____________________________________

1

For office use only
Date processed by Universal Healthcare Services: ............................................................................................

Agent’s Details:

Date:

.....................................................................................................................

Agency name:

.....................................................................................................................

Agent name and surname:

.....................................................................................................................

FSB / BR number (if applicable):

..............................................................................................................