Panchayat:Repo18/Law Manual Page0610 - Revision history

Rtv1972: '
'''FORM 4'''

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

2019-01-24T07:39:50Z

'<div style="text-align: center;">'''FORM 4'''</div> <div style="text-align: center;">[See sub-rule (2) of Rule 4]</div> <d...' താൾ സൃഷ്ടിച്ചിരിക്കുന്നു

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<div style="text-align: center;">'''FORM 4'''</div>
<div style="text-align: center;">[See sub-rule (2) of Rule 4]</div>
<div style="text-align: center;">'''APPLICATION TO REGISTER AN EXISTING PRIVATE HOSPITAL OR
PRIVATE PARA MEDICAL INSTITUTION IN VILLAGE PANCHAYAT'''</div>

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: <div style="text-align: right;">Signature of applicant</div>
Date :
----
<div style="text-align: center;">'''For Office Use'''</div> 1.Date of receipt of application:

2.Whether registration fees has been remitted or not:

3.Enquiry report:

4.Number and date of registration

<div style="text-align: right;">Signature of Secretary </div>

<div style="text-align: center;">'''FORM 5'''</div>
<div style="text-align: center;">[See sub-rule (1) of Rule 5]</div>
<div style="text-align: center;">'''APPLICATION FOR RENEWAL OF REGISTRATION OF A PRIVATE HOSPITAL OR A PRIVATE PARA MEDICAL INSTITUTION REGISTERED IN VILLAGE PANCHAYAT'''</div>

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: <div style="text-align: right;">Signature of applicant</div>
Date :
<div style="text-align: center;">'''For Office Use'''</div> 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:

<div style="text-align: right;">Signature of Secretary </div>