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--MEMBERSHIP CONTRACT FORM--
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1- DETAILS OF THE HEALTHCARE ESTABLISHMENT: ("THE GENERATOR")
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NAME OF THE HEALTH CARE ESTABLISHMENT:
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ADDRESS 1:
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ADDRESS 2:
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ADDRESS 3:
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LANDMARK:
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PIN CODE:
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CITY:
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STATE:
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EMAIL*
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TEL NO.
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NAME OF THE PERSON IN-CHARGE:Dr.
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MEDICAL COUNCIL REGISTRATION NO:
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MEDICAL COUNSIL OF INDIA REGISTRATION COPY:
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PDF format only.
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RESIDENTIAL ADDRESS:
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MOBILE NO -
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PERSON RESPONSIBLE TO HANDLE BIO-MEDICAL WASTE: MR./MS./DR.
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MOB.NO 1 -
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2 -
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NORMAL WORKING TIME:
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2- TYPE/ CATEGORY OF THE HEALTHCARE DEVELOPMENT
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CATEGORY
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SUB CATEGORY
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ADDITIONAL CATEGORY -
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TOTAL NO. OF BEDS
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As per BMW Rules Readable Bar Code Stickers on Biomedical waste disposal bags are mandatory so please implement Bar Coding services on immediate basis.
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TOTAL NO. OF OPD
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TOTAL NO. OF BLOOD BANK
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TOTAL NO. OF LAB
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TOTAL NO. OF DENTAL CHAIR
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3- CHARGES: -
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REGISTRATION CHARGES RS.
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SERVICE CHARGES RS.
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ASSURED WT.(KG.)-
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EXCESS WT RATE-
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ALL THE ABOVE DOCUMENT ARE MENDENTORY
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PAN NO -
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Please upload PAN Card
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GSTN NO-
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Please upload GST File
I/We hereby declare that I/We do not have GST Number currently, I/We shall submit GST
Number via registered/speed post at address bellow, alongwith GST Certificate. If obtain in future.
ADDRESS : 313, Kha, Village Bindawada, Tehsil Mohanlalganj, Lucknow 226010
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4- PERIOD
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MEMBERSHIP CONTRACT EFFECTIVE FROM
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5.ANY ADDITIONAL INCREASE IN THE RATES APPROVED BY MCGM OR GOVT. AUTHORITY WILL BE PAYABLE WITH
IMMEDIATE EFFECT DURING THE ENFORCEMENT PERIOD OF THE CONTRACT.
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Bank Name : Punjab National Bank
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BRANCH : Dharampeth Nagpur
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ACCOUNT NUMBER : 3761002100024594
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BANK BRANCH IFSC : PUNB0376100
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UTR NO
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DATE OF TRANSACTION
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YEARLY CHARGES (RS.):
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DEPOSIT AMOUNT (RS.):
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TOTAL RECEIVED (RS.):
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CHEQUE NO.:
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DATED:
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BANK:
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Transaction Number :
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CLIENT VERIFICATION.
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ADHAR CARD NO:
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ADHAR CARD:
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PDF format only.
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ADDRESS VERIFICATION DOCUMENT.
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ELECTRICITY BILL:
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PDF format only.
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TELEPHONE & MOBILE BILL:
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PDF format only.
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UDHYAM ADHAR:
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PDF format only.
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LEASE AGREEMENT:
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PDF format only.
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MEMBERSHIP WILL BE VALID SUBJECT TO THE REALIZATION OF CHEQUE.
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CONFIRM & ACCEPTED
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MEMBER SIGNATURE/SEAL
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Signature Upload upto 2MB
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PHOTOGRAPH
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Photo Upload upto 2MB
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