APPLICATION FOR REGISTRATION
OF HEALTHCARE SERVICE PROVIDERS
Healthcare Service Provider is required to complete this form as per the requirements of the provisions of Punjab Healthcare Commission Act 2010.
Incomplete forms will not be entertained.
Provision of incorrect information/documents will result in rejection of the Application.
Return the completed form to:
Directorate of Licensing & Accreditation,
Punjab Healthcare Commission
Office # 1 & 2, 4th FloorShaheen Complex, 38-Abbot Road, Lahore
For further information, please visit our web site: www.phc.org.pk
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HEALTHCARE SERVICE PROVIDER |
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Name: |
Designation: _________________________
Status: Owner |
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Qualification:
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CNIC Number:
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Registration No. PMDC/ PNC/ NCH/ NCT:
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Mailing Address:
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Town:
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City: |
District: Punjab |
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Telephone (landline & mobile)
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Fax: |
Email: |
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HEALTHCARE ESTABLISHMENT |
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Name: |
Date of establishment at present location: (Day/Month/Year)
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Previous Name (If any):
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Mailing Address:
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Town:
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City: |
District: Punjab |
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Telephone (landline & mobile)
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Fax: |
Email:
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TYPE OF ORGANIZATION |
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Type of Ownership (please check the appropriate box)
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Government |
Others |
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£ District Government |
£ Sole Proprietary |
£ Voluntary Non- Profit |
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£ Provincial Government* |
£ Partnership |
£ Association |
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£ Federal Government |
£ Corporation |
£ Limited Liability Company (Private) |
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£ Autonomous Institution |
£ Trust |
£ Limited Liability Company (Public) |
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£ CMH/ Cantonment Hospital |
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If incorporated or registered, date of incorporation/No & organization it is registered with: |
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*Provincial government includes Social Security, Auqaf department & family planning department etc
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TYPE OF HEALTHCARE ESTABLISHMENT (please check the relevant box) |
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£ Teaching
£ Non-Teaching
£ Single Specialty (please specify): _____________________________________________________
£ Multiple Specialty
£ Others GP Clinic/ Homeopath/ Hakim/ Lab/ Radiological or Imaging/Maternity or Nursing homes/ Dental clinic/ Cosmetic Surgery/ Laser Clinic/ If any other please specify: ____________________
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BED STRENGTH |
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£ Number of Beds: ____________ |
ATTESTATION
I, the undersigned, do hereby solemnly affirm and declare that the information provided above is true and correct to the best of my knowledge and belief and that nothing has been concealed therefrom. I also state that if any false or incorrect information is provided to the Commission, it may result in rejection of my application for registration and I may also be found liable to pay fine to the Commission.
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Signature |
Name of Applicant
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Date
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Designation
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