FORM II
(See Rule 15)
Application for establishment of psychiatric hospital/ nursing home under sub-section (2) of Sec. 7

To
The ……………..
Government ......................
Dear Sir/Madam,
I/We intended to establish a psychiatric nursing home/psychiatric hospital at …………. (mention the place). I am herewith giving you the details.
1. Name of Applicant.
2. Qualification of Medical Officer to be in charge of nursing home/hospital (Certificates to be attached).
3. Age …………….
4. Professional experience in Psychiatry. Permanent Address of the applicant.
6. Location of the proposed hospital/nursing home.
7. Address of the proposed nursing home/hospital.
8. Proposed accommodations :-
(a) Number of rooms.
(b) Number of beds.
Facilities provided :-
(a) Out patient.
(b) Emergency services.
(c) Inpatient facilities.
(d) Occupational and recreational facilities.
(e) ECI' facilities.
(f) X-ray facilities.
(g) Psychological testing facilities.
(h) Investigation and Laboratory facilities.
(i) Treatment facilities.
Staff Pattern :-
(a) Number of Doctors.
(b) Number of Nurses.
(c) Number of Attenders.
(d) Others.
I am herewith sending a bank draft for Rs ………….drawn in favour of ………..as licence fee
I hereby undertake to abide by the rules and regulation of the Mental Health Authority. I request you to consider my application and grant licence.
Yours faithfully,
Signature……….
Name…………..
Date……………