Proforma

1. Hospital Detail:
Hospital Name: ___________________________________________________
Govt. or Private: __________________Secondary/Tertiary:_________________
Available Beds: ___________________________________________________
2. Address:
________________________________________________________________
________________________________________________________________
Tehsil: ______________________ District: _____________________________
3. Contact Detail of Hospital:
Landline No._______________________ Fax No.________________________
E-mail______________________________________
4. Geographical Location:
Latitude: _______________________ Longitude: ________________________
5. Focal Person:
Name: _______________________________ Designation: ________________
Mob: _____________________________ Landline: ______________________
6. Bank Detail of Hospital:
Bank Name: ______________________________________________________
Account Title: _____________________________________________________
Bank Account Number: _____________________________________________
7. Tax:
NTN/FTN Number: ___________________________ NTN Category: _________
CNIC Number (if individual Category): __________________________________
NTN Status: ___________________ Applicable WHT/GST rate______________
8. DMO Detail:
Name: ______________________________ State Life/Prime HR____________
Mob: ___________________________ E-mail: _________________________
9. HFO Detail:
Name: ______________________________ State Life/Prime HR____________
Mob: _______________________________ E-mail: ______________________