SMS ENVOCLEAN Private Limited
United Registrar of Systems OHSAS 18001:2007, ISO 9001,
ISO 14001 Certified
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--MEMBERSHIP CONTRACT FORM--
1- DETAILS OF THE HEALTHCARE ESTABLISHMENT: ("THE GENERATOR")
NAME OF THE HEALTH CARE ESTABLISHMENT:
ADDRESS 1:
ADDRESS 2:
ADDRESS 3:
LANDMARK:
PIN CODE:
CITY:
STATE:
Andhra Pradesh
Andaman and Nicobar Islands
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadar and Nagar Haveli
Daman and Diu
Delhi
Lakshadweep
Puducherry
Goa
Gujarat
Haryana
Himachal
Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
MCGM WARD:
A
B
C
D
E
F-N
F-S
G-N
G-S
H-E
H-W
K-E
K-W
L
M-E
M-W
N
P-N
P-S
R-C
R-N
R-S
S
T
TEL NO.
EMAIL
NAME OF THE PERSON IN-CHARGE:Dr.
MEDICAL COUNCIL REGISTRATION NO:
RESIDENTIAL ADDRESS:
MOBILE NO -
PERSON RESPONSIBLE TO HANDLE BIO-MEDICAL WASTE: MR./MS./DR.
MOB.NO 1 -
2 -
MEMBERSHIP STATUS:
RENEWAL
NEW
SAP CODE NO:
NORMAL WORKING TIME:
2- TYPE/ CATEGORY OF THE HEALTHCARE DEVELOPMENT
CATEGORY
ANIMAL HOUSES/VATERNITY/RESEARCH INSTITUTE
BLOOD BANK, EYE BANK, SEMEN BANK, ORGAN TRANSPLANT
HOSPITAL
DISPENSARY
HEALTH POST
CLINIC/DISPENSARIES/GENERAL PRACTIONERS
PATHOLOGY LAB
PHARMA CLIENT
PRIVATE HOSPITAL - KDMC
CLINIC/DISPENSARIES/GENERAL PRACTIONERS - KDMC
PATHOLOGY LAB - KDMC
GOVERNMENT HOSPITALS - KDMC
OTHERS
SUB CATEGORY
Private
Brihanmumbai muncipal Corporation
Central Government
ADDITIONAL CATEGORY -
TOTAL NO. OF BEDS BELOW 50
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
41
42
43
44
45
46
47
48
49
50
TOTAL NO. OF BEDS ABOVE 50
TOTAL NO. OF OPD
TOTAL NO. OF BLOOD BANK
TOTAL NO. OF LAB
TOTAL NO. OF DENTAL CHAIR
3- CHARGES: -
REGISTRATION CHARGES RS.
SERVICE CHARGES RS.
ASSURED WT.(KG.)-
EXCESS WT RATE-
4- DOCUMENT ATTACHED-
*YOU CAN ATTACH UP TO 2MB JPG, DOC, XLS, PDF OR ZIP FILE
MCGM C FORM-
MPCB CONSENT-
*ALL THE ABOVE DOCUMENT ARE MENDENTORY
PAN NO -
GSTN NO-
4- PERIOD
MEMBERSHIP CONTRACT EFFECTIVE FROM
5.ANY ADDITIONAL INCREASE IN THE RATES APPROVED BY MCGM OR GOVT. AUTHORITY WILL BE PAYABLE WITH IMMEDIATE EFFECT DURING THE ENFORCEMENT PERIOD OF THE CONTRACT.
Bank Name : AXIS BANK
BRANCH CODE : 63
ACCOUNT NUMBER : 917020033688094
MICR NO.: 400211012
BANK BRANCH IFSC : UTIB0000063
UTR NO
DATE OF TRANSACTION
6.PAYMENT RECEIVED: (TO BE FILLED BY NEW MEMBER ONLY): REGISTRATION CHARGES RS
YEARLY CHARGES (RS.):
DEPOSIT AMOUNT (RS.):
TOTAL RECEIVED (RS.):
CHEQUE NO.:
DATED:
DRAWN ON:
BANK:
Transaction Number :
* MEMBERSHIP WILL BE VALID SUBJECT TO THE REALIZATION OF CHEQUE.
CONFIRM & ACCEPTED
MEMBER SIGNATURE/SEAL
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PHOTOGRAPH
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