Download Application Form for Complaints regarding Medical Health: Ulhasnagar

ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT: - COMPLAINTS REGARDING MEDICAL HEALTH Token Number (For Office Use) Date:- / / Citizen Identification Number (If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Last Name/ Surname Name Father/Husband's Name Details of Society (If Application from Society): Name Of Society: Designation Address: Head Information House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Wards Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Telephone No. (if any): Contact Person: Email Address (if any): Classification: - (Tick [ ] whichever applicable) [ ] Starting of Hospital/Medical centre/Nursing home/Dispensary etc. without proper permission [ ] Bogus Doctor [ ] Dispersion of infective diseases [ ] Nursing home Registration /Renewal [ ] Others Details of Complaint:- Applicant's Signature [Note: - Please attach necessary documents regarding Complaint.]