Registration

Service Provider Partner Details

Limited Company Name*
Trading As
Address 1*
Address 2
Town*
Post Code*
Telephone Number
Person in charge of Covid testing at Site
Trading Name
Address 1
Address 2
Town
Post Code
Site Telephone (If Different)
Person in charge of Covid testing at Site

Ownership Details

Owner/Director/Partner Name
Email Address
Telephone Number

Bank details

Name of Bank
Sort Code
Account Number
Account Name

Accounts Details

Name
Email Address
Telephone Number

Service Provider Staff Details

Full Name
Regulatory Body
Registration Number

Terms & Conditions

Name of person completing the form*
Email Address*
   I agree with Terms & Conditions*.