DEPARTMENT OF HEALTH AND FAMILY WELFARE

FORM I
[See rules 5(1)]

APPLICATION FOR REGISTRATION OF NURSING HOME

Service Type

Applying for *

---pendingNotExist---

Fresh

Renewal

---pendingEnd--- ---pendingExist--- ---pendingEnd---

Application Reference Number

1.Title *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

1.Applicant's Name *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Applicant Details

1.Upload Passport Photograph * Image size should be less than 250KB

---pendingNotExist---

---pendingEnd--- ---pendingExist---

---pendingEnd---

2.Address of the Applicant *

2.District *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

2.Village/Town *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

2.Locality *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

2.Post Office *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

2.Police Station *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

2.Pincode *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Nursing Home Details

3.Capacity while applying (Specify Owner/Partner/Managing Director/Other to be named) *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

4.Types of Services rendered by the Nursing Home.

Type of Service *

Name of Doctor in charge of Service/Discipline *

Age *

Qualification with registration Number(attested copies to be furnished) *

---pendingNotExist--- Type of Service * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Name of Doctor in charge of Service/Discipline * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Age * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Qualification with registration Number(attested copies to be furnished) * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

5.Type of Diagnostic facilities provided by the Nursing Home

Type of Diagnostic facilities available *

Equipment with make/model *

Name of Person in Charge *

Age *

Qualification with registration Number(attested copies to be furnished) *

---pendingNotExist--- Type of Diagnostic facilities available * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Equipment with make/model * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Name of Person in Charge * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Age * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

---pendingNotExist--- Qualification with registration Number(attested copies to be furnished) * ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Section

6.Name of the Nursing Home *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.Location *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.Post Office *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.Police Station *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.District *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.Pincode *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

6.Mobile Number *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

7.Type of Ownership and organization *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

7.Give Details *

---pendingNotExist--- ---pendingEnd--- ---pendingExist--- ---pendingEnd---

Declaration

I do hereby declare that all the particulars furnished in this application are correct to the best of my knowledge. I shall be held responsible for any incorrect information.

I Agree *