--MEMBERSHIP CONTRACT FORM--
1- DETAILS OF THE HEALTHCARE ESTABLISHMENT: ("THE GENERATOR")
NAME OF THE HEALTH CARE ESTABLISHMENT:
ADDRESS 1: ADDRESS 2: ADDRESS 3:
LANDMARK: PIN CODE:
CITY: STATE:
MCGM WARD: TEL NO.
EMAIL*
NAME OF THE PERSON IN-CHARGE:Dr.
MEDICAL COUNCIL REGISTRATION NO: MEDICAL COUNSIL OF INDIA REGISTRATION COPY:
PDF format only.
RESIDENTIAL ADDRESS:
MOBILE NO -
PERSON RESPONSIBLE TO HANDLE BIO-MEDICAL WASTE: MR./MS./DR.
MOB.NO 1 - 2 -
NORMAL WORKING TIME:
2- TYPE/ CATEGORY OF THE HEALTHCARE DEVELOPMENT
CATEGORY SUB CATEGORY
ADDITIONAL CATEGORY -
TOTAL NO. OF BEDS
As per BMW Rules Readable Bar Code Stickers on Biomedical waste disposal bags are mandatory so please implement Bar Coding services on immediate basis.
TOTAL NO. OF OPD
TOTAL NO. OF BLOOD BANK
TOTAL NO. OF LAB
TOTAL NO. OF DENTAL CHAIR
3- CHARGES: -
REGISTRATION CHARGES RS. SERVICE CHARGES RS.
ASSURED WT.(KG.)- EXCESS WT RATE-
4- DOCUMENT ATTACHED-
YOU CAN ATTACH UP TO 2MB JPG, DOC, XLS, PDF OR ZIP FILE
MCGM C FORM- MPCB CONSENT-
ALL THE ABOVE DOCUMENT ARE MENDENTORY
PAN NO -
Please upload PAN Card
 GSTN NO-
Please upload GST File

I/We hereby declare that I/We do not have GST Number currently, I/We shall submit GST Number via registered/speed post at number bellow, alongwith GST Certificate. If obtain in future.
4- PERIOD MEMBERSHIP CONTRACT EFFECTIVE FROM
5.ANY ADDITIONAL INCREASE IN THE RATES APPROVED BY MCGM OR GOVT. AUTHORITY WILL BE PAYABLE WITH
IMMEDIATE EFFECT DURING THE ENFORCEMENT PERIOD OF THE CONTRACT.
Bank Name : AXIS BANK
BRANCH CODE : 000048
ACCOUNT NUMBER : 917030028733313
MICR NO.: 440211002
BANK BRANCH IFSC : UTIB0000048
BANK BRANCH : CIVIL LINE NAGPUR
UTR NO DATE OF TRANSACTION
6.PAYMENT RECEIVED: (TO BE FILLED BY NEW MEMBER ONLY): REGISTRATION CHARGES RS
YEARLY CHARGES (RS.): DEPOSIT AMOUNT (RS.):
TOTAL RECEIVED (RS.): CHEQUE NO.: DATED:
DRAWN ON: BANK:
Transaction Number :
CLIENT VERIFICATION.
ADHAR CARD NO: ADHAR CARD:
PDF format only.
ADDRESS VERIFICATION DOCUMENT.
ELECTRICITY BILL:
PDF format only.

 TELEPHONE & MOBILE BILL:
PDF format only.
UDHYAM ADHAR:
PDF format only.

 LEASE AGREEMENT:
PDF format only.
LETTER HEAD (SELF ATTACHED):
PDF format only.
MEMBERSHIP WILL BE VALID SUBJECT TO THE REALIZATION OF CHEQUE.
CONFIRM & ACCEPTED
MEMBER SIGNATURE/SEAL
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 PHOTOGRAPH

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