Application Form for Recognition of Ayush Hospitals/ Day Care Centres/ Clinics

Annex 1 of System for Grant of Ayush Quality Mark to Ayush Hospitals/ Day Care Centres/ ClinicsApplication Form for Recognition of Ayush Hospitals/ Day Care Centres/ Clinics

1.Name of Ayush Hospital/ Day Care Centre / Clinic* (Complete name as mentioned in document establishing the entity)

2. Address of Ayush Hospital/ Day Care Centre /Clinic (Complete address Premises Address with City, Pin Code & Sate/U.T., Country) Address*

City*

Pin Code*

State / U.T.*

Country*

3. Address of Regd. Office (if different from 2 above) Complete address with City, Pin Code & Sate/U.T., Country) Address*

City*

Pin Code*

State / U.T.*

Country*

4. Contact Details (Give Telephone No., Mobile Nos., Email Id)

Telephone No.*

Mobile No.*

Email Id*

5. Type of Organization & Legal Identity* (Proprietorship, Partnership, Ltd. Pvt. Ltd., LLP, Govt., PSU etc.)

6. Scale of Organization a) Large/MSME* b) In case of MSME, mention Udhyam/other relevant Registration Nos. & Date

7. Details of Registration as clinical establishment by appropriate authority (Attach copy of the certificate)

Minimum Pdf Size to 2 MB

8. Year of starting/functioning of Ayush Hospital/ Day Care centre /Clinic.*

9. Management of Organization* (Name & Designation of Top Management & Key Functionaries)

10. Personnel employed (Managerial, Medical professionals, part time workers, contractual personnel, volunteers and others) — Refer annexure HR

11. Geographical coverage of Ayush Hospital/ Day Care centre / Clinic activities (Give complete list of countries being served)

12. Patients/ Customer Data (Past 2 years period and number of patients/customers)

13. List of other Services Provided (Accommodation, travel, medical tourism etc.)

14. Accreditation/ Certification as Ayush Hospital/ Day Care centre / Clinic (Name of accreditation/ certification body and copy of certificate with scope and locations as issued by accreditation/ certification body, also mention the eligibility criteria as per clause 2.1 of System document)

Minimum Pdf Size to 2 MB

15. In case certified to ISO: 7101/9001 Please indicate dates of audit, names of auditors and mandays of audits for the current cycle starting from initial/ last recertification audit, as applicable.

16. Name and address of consulting agency/ consultant engaged, if any, for establishment of system as per standards.

17. Payment of Application Fees (Give details like Mode of Payment, Transaction Id, Payment Date, Cheque No & Bank etc.)

Account Name:	Ayush Export Promotion Council	Bank Name:	Axis Bank
Account Number:	926010005729791	IFSC Code:	UTIB0003108
Branch:	South Extension II, New Delhi, 110049	Account Type:	Current

Amount*

Mode of Payment*

Transaction Id*

Payment Date*

Remarks

Bank*

18. Any other Information (Give additional information, if any, which the applicant may like to submit in support of and relevant the application)

19. Declaration –

It is hereby declared that the information, as provided above are true and the documents attached in support of the application pertain to us and are authentic. I undertake to inform AYUSHEXCIL, in case there is status change in respect of any information or the attached document.

Authorized Name*

Designation*

Date*

* Application to be signed by Proprietor, Partner, Managing Director, Director, CEO etc. or in his absence, by his authorized representative