APPLICATION FORM – II

FORM II
(See rule 15)
Application to establish a Psychiatric hospital/Nursing home under sub-section (2) of section 7 of the Act.
To
	The Licensing Authority
	……………………………………………………
	……………………………………………………
Dear Sir/Madam,
I/We intend to establish a psychiatric hospital/psychiatric nursing home at…………………(mention place). I herewith give you the details:
1.	Name of Applicant	:
2.	Qualification of medical officer to be in charge of nursing home/hospital (Certificate to be attached)	:
3.	Age	:
4.	Professional experiences 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 the rules and regulations of the Mental Health Authority.
	I request you to consider my application and grant the licence.
		Yours faithfully,
Place :		Signature :
Date :		Name :