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RML Quality Assurance Program

Participant Enrollment Form

Cycle -1OYear 2021

please Fill Sign and stamp the Form (Every detail is mandatory).

Registration
New Registration Yes [] No

Renewal Reg istration Yes No . lf Yes - RML QAP Lab cocle M

LTT.
Name of LaboratorY I
(ii) Privat€
. Organzation (i) Government
(ii) Applied for
o ISO'15189 (i) Accredited

(iii) Non accreditated

(i) Accredited
( ii) Applied for
NABI
(iii) Non accreditated I
Size of Lab (i) Small Lab ( 1 -1 00 Patient/day)
(ii) Medium Lab (1 00-400 Patient/day)
(iii) Large Lab (>400 Patient/clay)
VfiIITE{IEG bor,atory f
owner r)
Name of Director / Pq s, S

.H Rono NAltc,N&t H nAl -1.'L

- AMgftA
Address INDuS l^tTFR NAIIONft L HDSPIT*L
o State r Pin code l+oSO +
o city MoHru tDrr+aesrr) PUru YRA
o Mobile no 1246 tro++3S 1le t
[)hone No 6
eo
Errrail Address l,n

tant Pathologist & l/ or Microbiologis

Name of Consul

o Name KU' H N^YYAR

D A. AN .CAm
oEm ail Address ank,r.rsh.
o Phone No +z?L oo q L| I
ffiAnf contact P.gEen
Narne DR . ANKU s N EY q o{fr
o Email Address
I Phone No 6
 &'FeesrDeta'ils
GST)
Fields Total Annual Charges (Fees+Handling Charges+ l8o/o
Rs.-5 5O0/
Clinical Bio Chemistry Bio-O1 (Basic)
. Clinical Bio Chemistry Bio-02(Extended) Rs-700O/
Pleast ( hoose tthiel Bn!(ll or Bio-():
Rs-35OO/
. lmmunologY Rs-55O0/
. Hematology Rs-5500/
. Urine Routine AnalYsis Rs-6500/
. Histopathology Rs-5000/
. Cytopathology Rs-5000/
. Microbiology Rs-3000/
. Basic Serology Sero 01
Rs-3000/
. Extended Serology Sero 02
Rs-5000/
' HbAl c
Rs-5000/
*
' Antinuclears nntibotlies (ANA-lFA)
Rs-3 zooo/
' SARS-CoV-2

Participant GST Number

Dhtail of NEFT
. saction NO (rf
Tra n R,
" ),rh: 36al9i
. Accou nt Name RlvlL Rcsea rch Foundation Society
. Account No. 2009989851 I 6
o Name of the Bank lncJu sir.rd Eank Ltd
o Branclr Ground Floor, HT house 25, Ashok Marg
. City, State & Country Lucknow, Utter Pradesh & lndia
. IFSC Code rND800000't9
o GSTIN O9AABAR461 1A121

(oirc$pondance Address
Co-ordinator , RML Quality Assurance Program (Unit of RML Research Foundation Society)
PT
B-lTl,NiralaNagarLucknow-226020 Tel.No.0522-4034100Emai1 lD: rm lresearchfoundation@9 mail.com

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t/we , D8:t!gK!€_h_rv&I_Yit- for i,ru,g sufEt spFcrFd r.i.l H €ffLThr R(e p{TDiName of Lat)
Hereby declare that, lam /We are joining the tlML - QAP on purely volunta ry basis and that, I shall/We will abide
by the regulation laid in the Prograrnme.

p"1" lo. 9 &oA 3 DR. ANKUSH NAYYAR

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Starnped & Sig ned by
glntullant; PATtloLoolsT
Authorised Signahry
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