Panchayat:Repo18/Law Manual Page0610

FORM 4

[See sub-rule (2) of Rule 4]

APPLICATION TO REGISTER AN EXISTING PRIVATE HOSPITAL OR PRIVATE PARA MEDICAL INSTITUTION IN VILLAGE PANCHAYAT

1.Name and address of applicant:

2. Name and address of the existing private hospital / private para medical institution:

3. Date of starting of the institution:

4. Nature of functioning of the institution:

5. If a hospital, number of beds

6. (1) Number of doctors

(2) Number of other employees working in the institution

(category wise)

7. If a training centre, subjects in which training is given, facilities for training and number of trainees

8.Particulars regarding remittance of registration fee

Place:

Signature of applicant

Date :

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For Office Use

1.Date of receipt of application:

2.Whether registration fees has been remitted or not:

3.Enquiry report:

4.Number and date of registration

Signature of Secretary

FORM 5

[See sub-rule (1) of Rule 5]

APPLICATION FOR RENEWAL OF REGISTRATION OF A PRIVATE HOSPITAL OR A PRIVATE PARA MEDICAL INSTITUTION REGISTERED IN VILLAGE PANCHAYAT

1.Name and address of applicant:

2. Name and address of the private hospital / private para medical institution:

3. Registration number and date:

4. If a hospital, number of beds

5. (1) Number of doctors

(2) Number of other employees working in the institution

(category wise)

6. In the case of training centres if any, new training subject has been :

7.Particulars regarding the remittance of registration fees for renewal of registration

Place:

Signature of applicant

Date :

For Office Use

1.Date of receipt of application:

2.Whether registration fees has been remitted or not:

3.Particulars regarding annual fees levied

4. Whether registration is renewed or not (if not, state the reason briefly):

5. If the registration has been renewed the renewed registration number and date:

Signature of Secretary