| Part - I |
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| 1. |
Name of the applicant |
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(in BLOCK letters) |
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| 2. |
Complete Address with Pin code, telephone nos.,fax and e-mail)
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(in BLOCK letters) |
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| 3. |
(i) Status of applicant whether |
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State Government or Union Territory orUniversity or Trust
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(ii)Registration/incorporation |
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(Number and date, if any) |
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| 4. |
Name and address of the |
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Proposed Ayurved or Siddha or Unani Tibb or SowaRigpa College
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| 5. |
Date of 'No Objection Certificate' |
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issued by the State Government or UnionTerritory Administration.
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| 6. |
(i) Name and address of Affiliating University |
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(ii) Date of affiliation for the scheme |
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| 7. |
(i) Name of the proposed medical college |
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(ii) Name of the attached Hospital of Proposedmedical college
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(iii) ate of establishment of Hospital |
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| Part I |
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| 8. |
Basic Infrastructure |
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Facilities available for Medical college andattached Hospital
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(Attach separate sheet if necessary) |
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| 9. |
Composition of the Trust |
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Particulars of members of the Society or Trust,Head or Project Director of the proposed Medical College, head ofthe existing Hospital, Qualifications and
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Experience in the field of Medical education ofmembers, Head of Project or Director and head of the Hospital.
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| 10. |
Financial Capability |
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(Balance sheet for the last three years to beprovided if the applicant is a Trust.
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Details of the resources to be prescribed). |
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| 11. |
Characteristics of proposed site of theMedical College: -
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(a) topography |
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(b) plot size |
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(c) permissible floor space index |
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(d) ground coverage |
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(e) building height |
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(f) road access |
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(g) availability of public transport |
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(h) electric supply |
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(i) water Supply |
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(j) sewerage connection |
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(k) communication facilities |
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(l) Master Plan of the proposed Medical College |
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(m) Layout plans, sections |
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(n) elevations and floor wise area calculations |
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| 12. |
Educational Programme |
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(a) proposed annual intake capacity of students |
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(b) mode of admission |
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(c) reservation/preferential allocation ofseats.
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| 13. |
Functional programme |
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(a) Department wise and service wise functionalrequirements
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(b) Area distribution and room wise sittingcapacity.
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| 14. |
Equipment programme |
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Department wise list of equipments with yearwise schedule of quantities and specifications -
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(a) medical equipments |
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(b) scientific equipments |
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(c) allied equipments |
____________________________ |
| 15. |
Man-power programme |
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Department wise andyear wise provisions -
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(a) full time teaching staff |
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(b) technical staff |
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(c) administrative staff |
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(d) ancillary staff |
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(e) salary structure |
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(f) mode of payment of salary |
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(g) recruitment procedure |
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(h) recruitment calendar |
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| 16. |
Building programme |
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(a) departments, lecture theatres, |
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examination hall, museum etc. |
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(b) staff quarters |
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(c) staff and students hostels |
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(d) administrative office |
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(e) library |
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(f) auditorium |
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(g) teaching pharmacy |
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(h) mortuary _________________________ |
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(i) cultural and recreational center |
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(j) sports complex _________________________ |
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(k) medicinal plants garden |
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(l) Other facilities(state name of other facilities)
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| 17. |
Proposed Phase programme and quarter wiseschedule of activities indicating -
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(a) commencement and completion of buildingdesign
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(b) local body approvals |
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(c) civil construction |
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(d) provision of engineering services andequipments
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(e) requirement of staff |
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(f) schedule of admission |
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| 18. |
Project cost |
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(a) capital cost of land |
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(b) buildings |
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(c) plant and machinery |
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(d) medical, scientific and allied equipments |
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(e) furniture and fixtures |
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(f) Preliminary and preoperative expenses________________________
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| 19. |
Means of financing the project |
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(a) contribution of the applicant |
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(b) grants |
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(c) donations |
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(d) equity |
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(e) term loans |
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(f) other sources, if any |
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| 20. |
Revenue assumptions |
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(a) fee structure |
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(b) hospital user charges |
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(c) estimated annual revenue from varioussources
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| 21. |
Expenditure assumptions |
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(a) operating expenses |
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(b) depreciation |
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| 22. |
Operating results |
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(a) income statement |
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(b) cash flow statement |
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(c) projected balance sheets |
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| 23. |
Name, address anddetails of the existing hospital
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(a) bed strength |
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(b) bed distribution, bed occupancy and whetherthe norms specified in Minimum Standard Requirements
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Regulations of the concerned system of IndianMedicine would be fulfilled.
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(c) built up area |
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(d) clinical and para clinical disciplines |
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(e) number of out patient departments anddepartment wise attendance
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(f) architectural and layout plans |
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(g) list of medical/allied equipments |
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(h) capacity and configuration of engineeringservices
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(i) hospital services, administrative |
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services, other ancillary and support services(category wise staff strength)
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| Part II |
| Upgradation and Expansion Programme: |
| 24. |
Details about theadditional
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land for expansion of the existing hospital |
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(a) land particulars |
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(b) location of medical college and proposedhospital
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(c) topography |
______________________________ |
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(d) plot size |
______________________________ |
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(e) permissible floor space index |
______________________________ |
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(f) ground coverage |
______________________________ |
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(g) building height |
______________________________ |
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(h) road access |
______________________________ |
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(i) availability of public transport |
______________________________ |
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(j) electric supply |
______________________________ |
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(k) water Supply |
______________________________ |
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(l) sewerage connection |
______________________________ |
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(m) communication facilities |
______________________________ |
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(n) Master Plan of the proposed Medical College |
______________________________ |
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(o) Layout plans, sections |
_______________________________ |
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(p) elevations and floor wise area calculations |
______________________________ |
| 25. |
Upgraded Clinical Programme: - |
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Year wise details of the additional |
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clinical and para clinical activities envisagedunder the expansion programme
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| 26. |
Upgraded functional programme: - |
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(a) specialty wise and service wise functionalrequirements
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(b) area distribution |
_____________________________ |
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(c) specialty wise bed distribution |
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| 27. |
Building expansion programme: - |
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Year wise additional built-up area to beprovided for -
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(a) departments, lecture theatres, examinationhall etc.
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________________________________ |
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(b) hospital |
________________________________ |
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(c) staff quarters |
________________________________ |
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(d) staff and students hostels |
________________________________ |
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(e) other ancillary buildings |
________________________________ |
| 28. |
Planning and Layout: - |
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Upgraded master plan of the hospital complexalong with:-
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(a) Layout plans |
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(b) Sections |
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(c) Elevations |
______________________________ |
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(d) Floor wise area calculation of the hospital |
______________________________ |
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(e) Floor wise area calculation of ancillarybuildings
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______________________________ |
| 29. |
Details about upgradation or addition in the capacity
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______________________________ |
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and configuration of engineering services and |
______________________________ |
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hospital services |
______________________________ |
| 30. |
Equipment programme: |
|
| |
Upgraded department wise list of equipments withyear wise schedule of quantities and specifications -
|
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(a) medical equipments |
______________________________ |
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(b) scientific equipments |
______________________________ |
| |
(c) allied equipments |
______________________________ |
| 31. |
Upgraded manpower programme: |
|
| |
Department wise and year wise provisions- |
|
| |
(a) full time teaching staff |
______________________________ |
| |
(b) technical staff |
______________________________ |
| |
(c) administrative staff |
______________________________ |
| |
(d) ancillary staff |
______________________________ |
| |
(e) salary structure |
______________________________ |
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(f) mode of payment of salary |
______________________________ |
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(g) recruitment procedure |
______________________________ |
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(h) recruitment calendar |
______________________________ |
| 32. |
Expansion of scheme- proposed phaseprogramme and quarter wise schedule of activities indicating -
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(a) commencement and completion of buildingdesign
|
______________________________ |
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(b) local body approvals |
______________________________ |
| |
(c) civil construction |
______________________________ |
| |
(d) provision of engineering and hospitalservices
|
______________________________ |
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(e) provision of medical and allied equipments |
______________________________ |
| |
(f) requirement of staff |
______________________________ |
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(g) schedule of admission |
______________________________ |
| 33. |
Project cost |
|
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(a) capital cost of land |
______________________________ |
| |
(b) buildings |
______________________________ |
| |
(c) plant and machinery |
______________________________ |
| |
(d) medical, scientific and allied equipments |
______________________________ |
| |
(e) furniture and fixtures |
______________________________ |
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(f) preliminary & preoperative expenses |
______________________________ |
| 34. |
Means of financing the project :- |
|
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(a) contribution of the applicant |
______________________________ |
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(b) grants |
______________________________ |
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(c) donations |
______________________________ |
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(d) equity |
______________________________ |
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(e) term loans |
______________________________ |
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(f) other sources, if any |
______________________________ |
| 35. |
Revenue assumptions |
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(a) fee structure |
_______________________________ |
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(b) hospital user charges |
_______________________________ |
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(c) estimated annual revenue from varioussources
|
_______________________________ |
| 36. |
Expenditure assumptions |
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(a) operating expenses |
________________________________ |
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(b) depreciation |
________________________________ |
| 37. |
Operating results |
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(a) income statement |
________________________________ |
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(b) cash flow statement |
________________________________ |
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(c) projected balance sheets |
________________________________ |
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Signature of applicant |
| List of enclosures: |
| 1. |
Certified copy of Bye Laws/Memorandum andArticles of Association/Trust deed.
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| 2. |
Certified copy of certificate ofregistration/incorporation.
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| 3. |
Annual reports and Audited Balance sheets forthe last three years.
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| 4. |
Certified copy of the title deeds of the totalavailable land as proof of ownership.
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| 5. |
Certified copy of zoning plans of the availablesites indicating their land use.
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| 6. |
Proof of ownership of existing hospital with beddistribution
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| 7. |
Certified copy of the 'No Objection Certificate'issued by the respective State Government or Union TerritoryAdministration.
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| 8. |
Certified copy of the consent of affiliationissued by a recognized University.
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| 9. |
Authorization letter addressed to the bankers ofthe applicant authorizing the Central Government/Central Councilof Indian Medicine to make independent enquiries regarding thefinancial track record of the applicant.
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| 10. |
Other enclosures as per the various parts ofapplications (Please indicate details).
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| Note: All the copies shall be self-attested. |