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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 :  
       

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