THE ANDHRA PRADESH PRIVATE HOSPITALS &

NURSING HOMES ASSOCIATION

Regd. No.1223/83 PH : 9246200377
IMA BUILDING, ELURU ROAD, GOVERNORPET, VIJAYAWADA - 520 002.

MEMBERSHIP APPLICATION FORM

To,
Govt. Registration No.
The Hon. Secretary,
Andhra Pradesh Private Hospitals & State Registration No.
Nursinh Homes Association (APNA)
Vijayawada. District Registration No.

Date
Dear Sir,

Kindly enroll our Hospital Nursing Home as Member of the Andhra Pradesh Private Hospitals & Nursing Homes Association

I/We are enclosing the subscription fees of Rs. for Life Membership

by Cash/Draft/Cheque No. Date

Bank Name

I/We are giving below the particulars of our Nursing Home/Hospitals :

I. Name of the Hospital/

Nursing Home with Address :

Branches if any (with address) :

if more specify

II. Represented by Dr. :

Qualifications
(Attach Copies)
III. Address :

Residence :
IV. Telephone No. :

No. of Beds :

V. Are you Member of other Associations IMA : ....................................................................

(Social or professional with Membeersip No.) Speciality Association ...........................................

Attach a Copy APPA. F.S.S. No....................................................
FBS (IMA) No: .......................................................
 SERVICE DETAILS

VI. SERVICES AVAILABLE :

a) Status of Nursing Home : Multispeciality / Single Speciality (name) / Maternity/Surgical/General
b) General Information : AMC, ICCU, Labour Room, Theatre (No’s), General Ward,
(Speciality Units) Paediatric FICU, Medical Legal Services etc.
: 1.___________ 2. ____________ 3. ____________ 4. _____________
c) Diagnostics Attached : 5.___________ 6. ____________ 7. ____________ 8. _____________
(If separate name, specify) : 1.___________ 2. ____________ 3. ____________ 4. _____________
: 5.___________ 6. ____________ 7. ____________ 8. _____________
d) PNDT Act : Are you registered under PNDT Act, if so (Attach copy) No. _________
VII. STAFF DETAILS :
1. Doctor’s (Nos.) : ________________________________________________________
2. Paramedicals (Nos.) : ________________________________________________________
3. Nurses (Nos.) : ________________________________________________________
4. Diagnostics (Nos.) : ________________________________________________________
5. IV Class (Nos.) : _______________________ Total Staff ________________________
6. Are your implementing Minimum Wages Act (attach a copy)
7. Are you giving coverage of PF to employees (attach a copy)
VIII. PHARMACY :
Is Pharmacy attached to the Hospital : Yes / No. (If yes furnish Lincense No.______________________)
IX. GARBAGE FACILITY :
Whether registered under A.P.P.C.B.? Yes / No. If yes attach copy.
If yes, name of the Bio-Medical Carrier ____________________ & Fees paid _____________________
If No how Bio-Medical Dispossable is done __________________________________________________
Like (Municipality Van, land filling etc.)
X. INSURANCE :
Is the Nursing Home / Hospital is insured : Yes / No
If Yes under P.P.W.S. of (IMA), Assured Rs.____________________________________________lakhs
General Insurance Assured Rs._____________________________________________________ lakhs
XI. INCOME TAX :
Is your Nursing Home covered under Income Tax : Yes / No
Is Yes, PAN / No.__________________________________
XII. STATUS OF THE NURSING HOME :
a. Rental / Proprietary / Partnershp / Societies / Pvt. Ltd. Public Limited / Corporate / Trust. (Attach a copy)
b. Is Residence of the Doctor attached to Nursing Home or different place.
c. Whether registered under MCH / Municipality & Taken Licence (attach a copy)/
MTP Licence from DME attach copy
d. Area under the hospital ______________________ sq. ft. (Plinth area)
tax paid Rs.____________________ per annum (Property tax receipt copy)
Life Membership fees : Rs.6000/- (Cheque/DD in Favour of “AP. Private Hospitals & Nursing Homes Association
Acceptance of Application is subject to Rules & Regulations of APNA.
Application form Rs.50/-.

SEAL & SIGNATURE OF THE OWNER (OR)

MEDICAL SUPERINTENDENT