Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
i) Name of the
Society/Institute/
01 (ii) Name of the Govt/Private
Medical College
iii) Postal Address, with PIN M: , T:
iv) Contact Details:
v) E-mail ID:
Society/Institution/College/ i) Public Trust Act 1950: . . . . . . . . . . . . . . . . . . . .
02 Hospital Registration Number ii) Society’s Registration Act 1860: . . . . . . . . . . .
and date:
iii) Year of establishment: . . . . . . . . . . . . . . . . . . .
iv) Copies of Registration, Constitution and Appendix ‘A’
Memorandum of
Association attached? *Yes/No.
v) Certificate of Registration under Bombay Shop
Act 1948.
06 Fee details:
Appendix ‘D’
(i) Amount Rs…………………………..
(ii) Mode of payment RTGs/NEFT/DD/pay online…….………..dated……….
(iii) DD/NEFT/RTGs Ref or UTR No & date……………….
(iv) Name of the bank & Branch……………………….
(Please attach receipt in case the fees paid by NEFT/RTGs/pay online)
07 Financial position of the Society/ Audited Statements of Accounts for i) 20 . . . - . . ,
Institute in the preceding 03 years: ii) 20 . . . - . . . , iii) 20 . . . - . . . attached? *Yes/No Appendix ‘E’
11 Teaching Staff
Sr. Name Qualification Experience Approved/Recognised
Appendix ‘G’
No by MUHS
with other library (ies)? Hospital: . . kms. ‘Permission Letter’ from the
concerned Library attached? *Yes/No.
13 Building : *Yes/No.
i) Administrative Block:
ii) Class Rooms: *Yes/No.
iii) Hospital Facilities: *Yes/No.
14 Laboratory : i) Affiliation with a *Yes/No. If yes, attach valid Memorandum of Appendix ‘M’
Laboratory/ Radiologists? Understanding.
ii) Research Laboratory *Yes/No. If available, state all details. Appendix ‘N’
available?
iii) Equipments/Instruments List attached? *Yes/No. Appendix ‘P’
available for the conduct of
Course:
15 Hostel: i) Boys: *Yes/No
16 Computer Laboratory: i) Quantity of computers:
ii) Internet facility: *Available/Not Available
iii) Own web site: *Available/Not Available
17 Seminar Hall: Minimum Capacity of 50 *Available/Not Available
Audience
18 Ethical Committee: *Available/Not Available
19 Hospital : Own 300 bedded Hospital *Yes/No.
20 i) Certificate of Registration under Appendix ‘Q’
Bombay Nursing Homes Act 1949.
ii) Letter of Bio-medical Waste Appendix ‘R’
Authorisation/Renewal application of
BMW authorization, issued by
Maharashtra Pollution Control Board
(iii) Built – up area:
iv) OPD/IPD (No. of patients per year): Speciality Paid Free Total
I/We solemnly declare that, all the information furnished above is true and correct to the best of my/our
knowledge.