FORM -1[(See rule 3(1)(2)and (10)]Application for Grant /Maintenance/Renewal of Certificate of Registration of Clinical Establishment1. I/Weofhereby apply for grant/ maintenance /renewal of Certificate of Registration for the purpose of running aPhysiotherapy Establishment /Maternity Home /Private Nursing Home /Clinical Establishment (pathology) Diagnostic Centre/Blood Bank /Medical Termination of Pregnancy Clinics/ X-ray instituteson the premises situation at2. The Clinical aspect in the above establishment will be made under the supervision of the followingtechnical persons :-Name (s)QualificationAddress(a)(b(cHealth & Family Welfare DepartmentGovernment of OrissaPublished on National Portal of India (india.gov.in) Name of Paramedical Persons:-TownMunicipalityPanchayatVillageestablishment.N.B. A fee of Rs. 10,000/-,Rs.8,000/- Rs.6,000/-, Rs 5,000/-only as per applicability has been credited Receipts from patients for Hospital and Dispensary Services -0010-charges for service provided 02087-other fees.Signature of ApplicantDateName (s)QualificationAddress(a)(b(c3.Population of the local area 45Number of Clinical Establishments within the radius of one Kilometer of the proposed clinical to Government under the head of Account"0210"-Medical and PH-01-Urban Health Services -020- Consent letters of the technical persons and paramedical persons to work for five years in yourestablishment duty signed by technical persons / paramedical persons is enclosed. Published on National Portal of India (india.gov.in)
