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Application Form for Registration of Clinical Establishments

1 Application Form for Registration of Clinical Establishments DETAILS of the establishment: _____ : _____ Village/Town:_____ Block:_____ District: _____State: _____ Pin code_____ Tel No (with STD code):_____Mobile: _____Fax : _____ Email ID : _____Website (if any): _____ and Year of starting: _____ (From 4 to 11 mark all whichever are applicable) 4. Location: Rural Urban Metro Notified / inaccessible areas (including Hilly / tribal areas) 5. Ownership of Services Government/Public Sector Central government State government Local government (Municipality, Zilla parishad, etc) Public Sector Undertaking Other ministries and departments (Railways, Police, etc.)

8. Systems of Medicine offered: (please tick whichever is applicable) Allopathy  Ayurveda  Unani Siddha  Homoeopathy Yoga Naturopathy Sowa-Rigpa  9. Type of establishment :( please tick whichever is applicable)  (I).Clinic (Outpatient)  Single practitioner

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