Medical Value Travel Facilitators [MVTFs]

1. Name of MVTF * (Complete name as mentioned in document establishing the entity)

2. Address of MVTF* (Complete address Premises Address with City, Pin Code & State/U.T., Country) Address Line*

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

4. Other location(s) of the Organization where also MVTF activities are carried out

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

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

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

8. Year of Registration/Establishment*

9. Year of starting/functioning of MVTF activities*

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

11. Personnel employed (Managerial, Medical professionals, Interpreter, part time workers, contractual personnel, volunteers and others)

12. Geographical coverage of MVT activities (Give complete list of countries being served)

13. Customer Data (Past 2 years – period and number of customers, if available)

14. List the Services Provided (Accommodation, travel, tourism etc.)

15. Accreditation/ Certification as MVTF (Name of accreditation/certification body and copy of certificate, also mention eligibility criteria as per clause 2.1 of System document) Upload Certificate

Minimum Pdf Size to 2 MB

16. List of Contracted Healthcare Providers (Also mention eligibility criteria as per clause 2.2 of System document)

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

18. Any other Information (Give additional information, if any, which the applicant may like to submit in support of and relevant to 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 the (PO), in case there is status change in respect of any information or the attached document.

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