Amendment status not verified — confirm the current text below against the official source.
Type of ownership and organisation (specify individual ownersbip/partnership/company/co-operative/any other) In case of type of organisation other than individual ownership, furnish copy of articles of association and names and addresses of other persons responsible for management, as enclosure. Type of Institution (Govt. Hospital/Municipal Hospital/ Public Hospital/Private Hospital/Private Nursing Home/ Private Clinic/Private Laboratory/any other to be stated. Specific prenatal diagnostic procedures/tests for which approval is sought (for example amniocentesis, chorionie villi aspiration/chromosomal/biochemical/molecular studies etc). Leave blank if registration sought for Genetic Councellin; Centre only (a) Space available for the Counselling Centre/Clinic/ Laboratory give total work area excluding lobbies. waiting rooms, stairs etc. and enclose plan) Equipment available with the make and model of each equipment. List to be attached on a separate sheet). (a) Facilities available in the Counselling Centre. (b) Whether facilities are available in the Laboratory/ Clinic for the following tests; (i) Ultrasound (ii) Amniocentesis (iii) Chorionie villi aspiration (iv) Foetoscopy (v) Foetal biopsy (vi) Cordocenteds (c) Whether facilities are available in the Laboratory Clinic for the following : (i) Chromosomal studies (ii) Biochemical studies (iii) Molecular studies Names, qualifications, experience and registration num- ber of employees. May be furnished as an enclosure. (Refer Schedules I, II or III) State whether the Genetic Co&nselling Centre,Genetic Laboratory/Genetic Clinic* qualifies for registration in terms of minimum requirements laid down in Schedule I, II and III and if not, reasons theiefoi. For renewal applications only : (aj Registration No. )b) Date of issue and date of expiry oi' existing certi- ficate of registration. List of Enclosures : Please attach a list of enclosures giving the supporting documents enclosed to this application. ( - ) Namt and signature of applicant Date : Place : 25 DECLARATION I, Sh./Smt./Kumi /Dr son/ daughter/wife cf aged years resident of hereby declare that 1 hav; read and understood the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act. 1994(57 of 1994) and the Pre-natal Diagnostic Techniques (Regulation nnd Prevention of Misuse), Rules, 1995 (ii) 1 also undertake to explain the said Act and Rules to all employees of the Genetic Counselling Centre/ Genetic Laboratory/GeneMc Clinic in rcspecfof Which registration is sought and to ousure that Act and rul.s aco fully complied with ( _ — ) Name and signature oi applicant Date : Place : *Strike out whichever is not applicable or not necessary. All enclosures are to be authenticated by signatui0 ol the applicant. ACKNOWLEDGEMENT [See rules 4(2) and 8(1)] The application in Form A in duplicate for grnnt*/'rene\val* nf registration of Gcnet'c Counselling Qntrt*/ Genetic Laboratory's/Genetic Cl;nic* by (Nams and address of applicant) has been received by the Appropratc. Authority on (date). •"The list of enclosures attached to the application in Form A has been verified with the enclosures submtted and found to be correct. OR "On verification it is found that following documents mentioned in the list of enclosures are not actually enclosed. This acknowledgement docs not confer any rghts on the applci,nt for grant or renewal of registration. ( _ _ ) Signature and Designation of Appropriate Authority, or authorized person in the office of the Appropriate Authority. Date : SEAL •"Strike out whichever is not applicable or noi necessary. 1 GI/96-4 26 THE GAZETTE OF INDIA : EXTRAORDINARY [PART I I - S E C . 3(1)) ORIGINAL* DUPLICATE FOR DISPLAY FORM B [See rules 6(2), 6(5) and 8(2) ] CERTIFICATE OF REGISTRATION l,To bs issued in duplicate)