New Registration Process

FORM  A

[See rules 4(1) and 8(1) ]

(To be submitted in Duplicate with supporting documents as enclosures)

FORM OF APPLICATION FOR REGISTRATION OR RENEWAL OF REGISTRATION OF A GENETIC COUNSELLING CENTRE/GENETIC LABORATORY/GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE

 

(Note : all * marked field are mandatory)
Owner Details
Name of the applicant *
(Indicate name of the organization sought to be registered)
 
Address of the Applicant*   
Centre Details
Type of facility to be registered*
(please specify  any combination of these)


Full name *  
Address
                                                Locality*   
                                                City*  
                                                State*  
                                                Pin*   
Telephone*   
Fax numbers*   
E-mail address*   
Type of ownership of Organization (any other to be specified).*
In case type of organization is other than individual ownership furnish copy of articles of association and names and addresses of other Person responsible for management, as en closure.
 
Type of Institution(any other to be stated.)*  
Specific pre-natal diagnostic procedures/tests or which approval is sought
      (a) Invasive *  

(b) Non–Invasive*

Leave blank if registration is sought for Genetic  Counselling Centre Only.

 

(a) Facilities available in the Counselling Centre. *

 
(b) Where facilities are or would be availble in the Laboratoryt/Clinic for the following  tests:*

(c). Whether facilities are available in the Laboratory, Clinic for the following:
State whether the Genetic Counselling Centre /Genetic Laboratory/ Genetic Clinic/ultrasound clinic / imaging centre qualfies for registration in terms of requirements laid down in Rule 3. *  
Renewal

For renewal applications only:

(a)    Registration No.
(b)   Date of issue of existing certificate of registration. (dd/mm/yyyy)
(c)   Date of expiry of existing certificate of registration. (dd/mm/yyyy)
Fee Details:
Draft No.*   Amount*   
Date of Issue*    Issuing Branch*  
Enclosures
13.

list of Enclosures:       

(please attach (scanned copy in picture format only) a list of enclosures/supporting document attached to this application.)

 (Enclosures to be in jpg, jpeg, gif and png format only)
1.   Select DD*   

2.   Select Qualification Certificate*    

3.    Select Registeration Certificate*  

4.   Select Affidavit*    
Date: 26-Sep-2017
Place:  *
 (----------------------------------------)
Name, designation and signature of the  Person authorized to sign

on behalf of the organization to be registered.