Notice inviting Expression of Interest for Operation and Management ...

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16. Declaration: This is to confirm that no litigation is pending on date and no penal measureswere taken against us under applicable Acts and laws17. List of documents submitted with the application (please tick)ooooCopy of Registration Details of the OrganizationMemorandum & Article of Association (if applicable)Copy of the partnership deed if it is a a partnership firmCopy of Balance Sheet for the last two financial yearsSignature:Name in full:Designation:Date:19
Annexure IIITo:OSD & E.O Special SecretaryHealth and Family Welfare Department,Government of West Bengal,MS Branch, PPP CellSwasthya Bhawan, 4 th Floor, Wing-‘B’GN 29, Salt Lake, Sector-VKolkata-700091Date:Sub: Concession Fee offered for operation and management ofDialysis Serviced / CT scan / Digital X-Ray (CR)Dear Sir,With reference to your advertisement dated ________ for selection of O&M partner foroperation and management of Dialysis Services / CT Scan / MRI Scan / Digital X-ray underPPP, given below are the details relating to our offer for concession fee for operation andmanagement of the specific services in the hospital as mentioned below:a. Name of the Hospital:b Name of the specific services to be provided:(Dialysis Unit /CT scan / Digital X-Ray CR)c. Our offer for Concession Fee for operation and management of the service asmentioned under ‘b’ above:-1. Percentage on Gross Quarterly Revenue*:(Both in figures and words)2. Fixed amount (in Rupees) to be paid in each Quarter:(Both in figures and words)The amount to be paid in each Quarter is either on percentage on gross quarterlyrevenue as mentioned under ‘c 1’ above or a fixed amount (in Rupees) in each Quarter asmentioned under ‘c 2’ above, which ever is higherWe the undersigned offer to undertake operation and management of the service asspecified under ‘b’ above in the Hospital mentioned above under PPP at a fixedconcession fee of Rs ________________ (Rupees---------------------------------) per eachQuarter or at the Percentage on Gross Quarterly Revenue as mentioned under ‘c 1’ abovewhich ever is higher.Signature of the applicant:Name in full & designation:Date:*Gross Quarterly Revenue for calculation includes all revenues and income in each quarterconnected to the operation and management of the specific services by the O&M partner underPPP in the hospital but excludes the service tax, sales tax and Value Added Tax (VAT).20
Page 1 and 2: GOVERNMENT OF WEST BENGALHEALTH & F
Page 3 and 4: Name of the HospitalDialysis Unit15
Page 5: ContentsSectionIContentsBackground2
Page 8 and 9: However, it is to be noted that pat
Page 10 and 11: eligible for free services as per g
Page 12 and 13: . ELIGIBILITY CRITERIA OF THE ORGAN
Page 14 and 15: CriteriaMarks3. For CT scan and Dig
Page 16 and 17: ANNEXURESAnnexure I:Instruction to
Page 19 and 20: (If the name/address is different t
Page 21: e. Existing Man Power for CT scan /
Page 25 and 26: Annexure VName of Health Facilities
Page 27 and 28: Annexure VI (continued)Rates of Dig

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