HOSPITAL (Archdiocese of Palo Annual General Statistics)

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Name of Institution: *

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Number *

Phone Number

Fax Number

Number of women assisted:

Number of men assisted:

TOTAL number of persons assisted: *

Number of women assisted:

Number of men assisted:

TOTAL number of persons assisted: *

Prepared by: *

First

Middle

Last

Signature: *

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Date of Completion *