Application Number: 19-535547(11/11/2019)

INTIMATION OF DECOMMISSIONING OF MEDICAL DIAGNOSTIC X-RAY EQUIPMENT

Application Number : 19-535547

Date of Application : 11/11/2019

Part A
Institute Details:
Name : KHALSA HOSPITAL MANAGEMENT
Permanent Address : INSIDE CHURAMANI COMPLEX ,CAMP CHOWK
Landmark : CAMP CHOWK
City : HISAR
State : HARYANA
Postal Code : 125001
Telephone Number :
Fax Number :
Email Id : kmhospitalhisar@gmail.com
Head of the Institute Details:
Name : ANIL JUNEJA
Designation : OWNER
Telephone Number(Office) : 01662225555
Mobile Number : 9896156789
Email Id : kmhospitalhisar@gmail.com
Licensee Details:
Name : ANIL JUNEJA
Designation : OWNER
Telephone Number(Office) : 01662225555
Mobile Number : 9896156789
Email Id : kmhospitalhisar@gmail.com

Part B
General Details:
Equipment Id : G-XR-120557
Manufacturer : M/s. Hindrays
Model : HR-300
Proposed date of Decommissioning of equipment : 12/11/2019
Agency responsible for decommissioning : HINDRAYS

Part C
UNDERTAKING

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 Application Number: 19-535547(11/11/2019)

I hereby certify that the particulars provided in this application are true and correct to the best of my knowledge and
belief. I understand that if at any stage it is found that the information provided by me is false or not authentic,
appropriate regulatory action may be initiated against me and my institution.

----------------------------------------------End of Application---------------------------------------------

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