FORM V
(See Rule 21)
Application for appeal

To
The Appellate Authority
Government of …………
Sir,
 I, Dr ……………. Of ………….. had applied for a licence for establishing a psychiatric nursing home/hospital at …………. Copy of the earlier application to be attached). My application was rejected by the licensing authority as per his/her letter No ………… dated ……... with the following reasons:
1.
2.
3.
(Copy enclosed)
The above reasons appear to be not valid. I request you to reconsider, my application.
My justifications are:
1.
2.
3.
I am willing to appear before you for a personal hearing if necessary. I am herewith enclosing a draft for Rs. 500.
Thanking you,                                                                                Yours faithfully,
Signature……………
Name…………….
Place ……….
Date ………….