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Establishing Diagnostic Services in Block Primary Health Centres ...

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Schedule -VIIIApplication Form for submission by the Private Party / NGO <strong>in</strong>tend<strong>in</strong>g to set up <strong>Diagnostic</strong> Unit<strong>in</strong> Rural Hospital / BPHC under Public Private Partnerships1. Name of the Rural Hospital / BPHC for which application is made:(Separate application is to be submitted for each Rural Hospital / BPHC)2. Name of the Organization / Firm / NGO:3. Complete Address of the Organization / Firm / NGO:4. Phone No. : Fax No. Email Id:5. Status of the Organization : Limited Company / Private Limited Company / Partnership Firm /Proprietorship Firm / NGO / Others (Specify with documentary evidence):6. Nature of Bus<strong>in</strong>ess Activities: <strong>Diagnostic</strong> Centre of the Applicant relat<strong>in</strong>g to Medical Profession(Please tick)a) Hospital with diagnostic facilitiesb) Nurs<strong>in</strong>g home with hospital facilitiesc) Dedicated <strong>Diagnostic</strong> Centred) Any other (specify)7. No. of years of operation of the exist<strong>in</strong>g <strong>Diagnostic</strong> Unit (Cl<strong>in</strong>ical Establishment):8. Registration details of the Organization / Firm / NGO (Whether registered under Company Act /Society Act etc. with documentary evidence)9. Details of Licence for the diagnostic unit (CE) of the organization under WB CE Act & Rules (Enclosecopies of license) :10. Annual Turn Over of the diagnostic unit (CE) for last three years with documentary evidence(Balance Sheet):11. Other <strong>in</strong>formation as required <strong>in</strong> terms of Eligibility Criteria & Selection Criteria <strong>in</strong> Schedule VII.SignatureName <strong>in</strong> FullDesignation <strong>in</strong> the OrganizationDateList of documents to be submitted with the application.1. Copy of the Registration details of the organiztion (refer item no. 8 of the application)2. Memorandum & Article of Association3. Copies of all relevant licenses (refer item no. 9 of the application)4. Copies of Balance Sheets for last 3 years5. Statement show<strong>in</strong>g <strong>in</strong>vestigation facilities provided <strong>in</strong> the exist<strong>in</strong>g diagnostic centre of the applicant.6. Specifications & Make of the equipment proposed to be <strong>in</strong>stalled <strong>in</strong> the diagnostic units <strong>in</strong> RuralHospital / BPHC applied for.7. Support<strong>in</strong>g documents <strong>in</strong> respect of the details of the Selection Criteria as referred to <strong>in</strong> paragraph 2of the document regard<strong>in</strong>g Selection Criteria (Schedule -VII )Dignostics Schemes-Feb 2010 (1 <strong>in</strong> all).doc 51 / 51

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