AFFIDAVIT

I__________________________________Smt/Sri/Dr________________________
Proprietor/Correspondent /Managing Director/Managing Partner /Medical
Director/Medical Superintendent of the _______________________________
___________________________________________________________________
(Full address of the Clinic/Nursing Home Hospital/Physiotherapy Unit /Dental
Unit/Diagnostic Centre Diagnostic centre with High end equipment centre) do hereby
declare that the building with the above address for running Clinic/Nursing Home
Hospital / Physiotherapy Unit/ Dental Unit Diagnostic Centre is constructed in plinth
area of x (example 30x50 = 1500 sq.fet) out of area of x =
(example 40x60 = 2400sq.fet ) and the height of building is below 15
meters i.e (actual building height) with floors (i.e C+G+2)
Further, I declare that, I have installed the appropriate efficient standard fire
fighting systems i.e., Fire Extinguishers and others in the premises of my institution
duly following the guidelines of A.P Allopathic Private Medical Care Establishment
Rules as stipulated in letter Rc.No.Spl/FF/DPH&FW/2015, dt:01.10.2015 of the
Director of Public Health & FW, AAP, Hyderabad and also I Shall abide to take other
precautionary measures in the above buildings to safeguard against fire accidents in
any occasions

Place: Signature of the Doctor/MD/Director/

Date: Proprietor/Correspondent
Hospital Seal /Stamp

(Note: Please get this affidavit typed on Rs.10/- Bond paper and get attested by
Notary before submission)