KNOW YOUR CLIENT (KYC) APPLICATION FORM FOR HEALTH CARE FACILITY (HCE)

{Please fill this form in ENGLISH and in BLOCK LETTERS)

A. IDENTITY DETAILS:

1. HCF Name: PREMIA MEDICARE

2. HCF Address: B-1, GREENWOODS CITY, SECTOR-45, GURUGRAM - 122001
3. Contact Name:
4. Email ID: premiapmedicarefo@gmail.com
5. Mobile No: 9810906789
6. Landline No: 0124 4555 777
7. PAN Number:
8. GST Number:
9. TAN Number (If Registered): (Mandatory if deduct TDS on service bill)
10. Signing Authority Pan No:
11. Signing Authority Aadhar Number:
12. Bedded/ Non-Bedded: Pathology Lab No of beds:
13. PCB Authorization No: Valid Up to:
14. HCF Opening & Closing business hours/days:

B. HCF BANK DETAILS

1. Bank Name:
2. Bank Account Number:
3. Bank IFSC Code:

DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge
and belief and I undertake to inform you of any changes therein, immediately.
In case any of above information is found to be false or untrue or misleading or misrepresenting, I am
aware that I may be held liable for it.

Signature of the Applicant Date: ______________________________ (DD/MM/YYYY)

Note: Please fill the enclosed KYC form. Kindly send one copy of Aadhar Card, PAN Card, GST
Registration if applicable, Pollution control Board (PCB) authorization and one passport size
photograph of the authorized signatory.
iv. The arbitration shall be sole and exclusive remedy between the Parties regarding the
Dispute referred to arbitration and any claims, counterclaims issues or accountings.
Presented to the arbitrators in connection with such dispute.
v. The Parties hereby undertake to implement the directions contained in the award.
Without delay. The costs and expenses of arbitration shall be paid as may be determined.
By the arbitrator.

18. That Occupier must intimate the Operator in writing in advance, preferably over an
Email, if the HCF is closed due to any reason. In absence of such intimation, Occupier
Shall be liable to pay the service charges.

19. THE WIINESS WHERE OF THE PARTIES HERE TO HAVE SET THEIR SIGNATURE AND SEAL NO THE
DAY AND YEAR MENTIONED HEREIN ABOVE.

BIOTIC WASTE LIMITED

(Authorized Signatory)
Plot no 725, pace city – II.
Sector 37, Gurugram – 122004, HR
9971794840, 9910728438
anup@biotic .co.in, gurgaon@biotic .co.in
GST:
MSME: HR -05-0001702

PREMIA MEDICARE

B-1, GREENWOODS CITY, SECTOR-45, GURUGRAM – 122001

9810906789
premiapmedicarefo@gmail.com

Witness: BIOTIC WASTE LIMITED

Witness: PREMIA MEDICARE