Engage Clinic · Vendor Registration

1

Company details

Use the legal name exactly as it appears on your trade licence.

Registered company name *

Trade name if different

Website

Registered or operating address *

City *

Emirate *

2

Contact person

The person our team will contact about orders, documents and reviews.

Full name *

Position *

Mobile number *

Email *

Alternate contact name & number, optional

Accounts / finance email

3

Category & services

Pick the category that best describes what you will supply to the clinic.

Primary service or product *

Brief description of your offer

Years in business

Referred by Engage staff member, if any

4

Compliance documents

Upload a clear copy of each document. We record the number, issue and expiry dates so we can remind you before anything lapses.

Trade Licence *

Not uploaded

File

Document number

Issue date

Expiry date

VAT Certificate Required if VAT registered

Not uploaded

File

Document number

Issue date

Expiry date

Insurance Certificate Liability or professional indemnity

Not uploaded

File

Document number

Issue date

Expiry date

Professional / Regulatory Licence e.g. DoH, Civil Defence, ADWEA approvals

Not uploaded

File

Document number

Issue date

Expiry date

Signed Contract / Service Agreement If already in place

Not uploaded

File

Document number

Issue date

Expiry date

Other Supporting Documents Company profile, certifications

Not uploaded

File

Document number

Issue date

Expiry date

Documents that expire within 30 days are flagged for renewal. Fire and life safety, security and CCTV, medical waste, cleaning, facility maintenance, IT systems and clinical supply vendors are reviewed as critical vendors and may be asked for extra documents.

5

Commercial terms

Your proposed terms. Final terms are confirmed in the agreement or purchase order.

Pricing / rate *

Estimated monthly cost AED

Payment terms *

Preferred payment method *

VAT registered? *

Yes No

Can you work against purchase orders?

Yes No

Proposed contract start

Proposed contract end

6

Bank details

Used for payments only. Our Finance team verifies these against your bank letter before the first payment.

Bank name *

Account holder name *

IBAN *

SWIFT / BIC

Bank letter or cancelled cheque *

7

Declaration

Engage works with children and families, so we hold every vendor to high standards of conduct and confidentiality.

The information and documents in this form are accurate and current. I will tell Engage about any change, including licence renewals. Our staff will keep any client, patient or clinic information confidential and will sign an NDA if requested. I understand that Engage reviews vendor performance periodically and may place a vendor on hold, suspend or end the relationship for compliance, quality or performance reasons.

Authorised signatory name *

Date

Become an Engage Community Partner

Company details

Contact person

Category & services

Compliance documents

Commercial terms

Bank details

Declaration

Registration received

Become an Engage Community Partner

Registration received

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