--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:
MCGM WARD: 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: RENEWALNEW
SAP CODE NO:
NORMAL WORKING TIME:
2- TYPE/ CATEGORY OF THE HEALTHCARE DEVELOPMENT
CATEGORY SUB CATEGORY
ADDITIONAL CATEGORY -
TOTAL NO. OF BEDS BELOW 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:
* MEMBERSHIP WILL BE VALID SUBJECT TO THE REALIZATION OF CHEQUE.
CONFIRM & ACCEPTED
MEMBER SIGNATURE/SEAL PHOTOGRAPH