--MEMBERSHIP CONTRACT FORM--

1- DETAILS OF THE HEALTHCARE ESTABLISHMENT: ("THE GENERATOR")

NAME OF THE HEALTH CARE ESTABLISHMENT:

ADDRESS 1:

ADDRESS 2:

ADDRESS 3:

LANDMARK:

PIN CODE:

CITY:

STATE:

Andhra PradeshAndaman and Nicobar IslandsArunachal PradeshAssamBiharChandigarhChhattisgarhDadar and Nagar HaveliDaman and DiuDelhiLakshadweepPuducherryGoaGujaratHaryanaHimachalPradeshJammu and KashmirJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest Bengal

EMAIL*

TEL NO.

NAME OF THE PERSON IN-CHARGE:Dr.

MEDICAL COUNCIL REGISTRATION NO:

MEDICAL COUNSIL OF INDIA REGISTRATION COPY:

PDF format only.

RESIDENTIAL ADDRESS:

MOBILE NO -

PERSON RESPONSIBLE TO HANDLE BIO-MEDICAL WASTE: MR./MS./DR.

MOB.NO 1 -

2 -

NORMAL WORKING TIME:

2- TYPE/ CATEGORY OF THE HEALTHCARE DEVELOPMENT

CATEGORY

Blood BankClinicDental ClinicDiagnostic CentreGovernment HospitalNursing HomePathological LabPrivate Hospital upto 7 bededPrivate Hospital above 7 bededResearch LabPharma (Destruction)

SUB CATEGORY

PrivateGovernment

ADDITIONAL CATEGORY -

TOTAL NO. OF BEDS

As per BMW Rules Readable Bar Code Stickers on Biomedical waste disposal bags are mandatory so please implement Bar Coding services on immediate basis.

TOTAL NO. OF OPD

TOTAL NO. OF BLOOD BANK

TOTAL NO. OF LAB

TOTAL NO. OF DENTAL CHAIR

3- CHARGES: -

REGISTRATION CHARGES RS.

SERVICE CHARGES RS.

ASSURED WT.(KG.)-

EXCESS WT RATE-

ALL THE ABOVE DOCUMENT ARE MENDENTORY

PAN NO -

Please upload PAN Card

GSTN NO-

ApplicableNon Applicable
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

4- PERIOD

MEMBERSHIP CONTRACT EFFECTIVE FROM

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.

Bank Name : Punjab National Bank

BRANCH : Dharampeth Nagpur

ACCOUNT NUMBER : 3761002100024594

BANK BRANCH IFSC : PUNB0376100

UTR NO

DATE OF TRANSACTION

YEARLY CHARGES (RS.):

DEPOSIT AMOUNT (RS.):

TOTAL RECEIVED (RS.):

CHEQUE NO.:

DATED:

BANK:

Transaction Number :

CLIENT VERIFICATION.

ADHAR CARD NO:

ADHAR CARD:

PDF format only.

ADDRESS VERIFICATION DOCUMENT.

ELECTRICITY BILL:

PDF format only.

TELEPHONE & MOBILE BILL:

PDF format only.

UDHYAM ADHAR:

PDF format only.

LEASE AGREEMENT:

PDF format only.

MEMBERSHIP WILL BE VALID SUBJECT TO THE REALIZATION OF CHEQUE.

CONFIRM & ACCEPTED

MEMBER SIGNATURE/SEAL

Signature Upload upto 2MB

PHOTOGRAPH

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