Licensing

FORM I
(See rule 15)
Application for maintaining a Psychiatric hospital/Nursing home under sub-section (1) of section 7 of the Act.
To
	The Licensing Authority
	……………………………………………………
	……………………………………………………
Dear Sir/Madam,
I/We intend to establish/maintain a psychiatric hospital/psychiatric nursing home in respect of which I am/we are holding a valid licence for the establishment/maintenance of such hospital/nursing home. The details of the hospital/nursing home are given below:
1.	Name of Applicant	:
2.	Details of licence with reference to the name of the Authority issuing the licence and date	:
3.	Age
4.	Professional experience in psychiatry
5.	Permanent address of the applicant
6.	Location of the proposed hospital/nursing home
7.	Address of the proposed nursing home/hospital
8.	Proposed accommodations
	(a) Number of rooms	:
	(b) Number of beds	:
Facilities provided :
	(a) Out-patient
	(b) Emergency services
	(c) In-patient facilities
	(d) Occupational and recreational facilities
	(e) ECT facilities
	(f) X-ray facilities
	(g) Psychological testing facilities
	(h) Investigation and Laboratory facilities
	(i) Treatment facilities
Staff pattern:
	(a) Number of Doctors	:
	(b) Number of Nurses	:
	(c) Number of Attenders	:
	(d) Others	:
	I am sending herewith a bank draft for ₹……………drawn in favour of………………….as licence fee.
	I hereby undertake to abide by the rules and regulations of the Mental Health Authority.
	I request you to consider my application and grant the licence for establishment/maintenance of psychiatric hospital/nursing home.
		Yours faithfully,
Place :		Signature :
Date :		Name :