RCCM: CD/L’SHI/RCCM/14-B-1265

ID NAT. N 6-9-N-96230H
N° d’Impôt A17022/QX Kolwezi, le ………/………../202……
Tél : +243 82 371 68 12/+243 97 396 88 83
E-mail : reservationharmonyinn@gmail.com
Av Honorable MBEMBA coin, LUFUPA, ville de
Kolwezi, Province du Lualaba R.D.Congo
www.harmonyinn.org

BON MEDICAL
NOM DE L’AGENT : ……………………………………………………………………………………….

MOTIF POUR VISITATION DE L’HOPITAL : ………………………………………………………….

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SIGNATURE DE L’AGENT SIGNATURE DU RESPONSABLE

RCCM: CD/L’SHI/RCCM/14-B-1265
ID NAT. N 6-9-N-96230H
N° d’Impôt A17022/QX
Kolwezi, le ………/………../202……
Tél : +243 82 371 68 12/+243 97 396 88 83
E-mail : reservationharmonyinn@gmail.com
Av Honorable MBEMBA coin, LUFUPA, ville de
Kolwezi, Province du Lualaba R.D.Congo
www.harmonyinn.org

BON MEDICAL
NOM DE L’AGENT : ……………………………………………………………………………………….

MOTIF POUR VISITATION DE L’HOPITAL : ………………………………………………………….

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

SIGNATURE DE L’AGENT SIGNATURE DU RESPONSABLE

BON MEDICAL

BON MEDICAL