PART-II
CENT-DOCTOR
(Please fill PART-I –Common Application Form)

01 NAME OF THE UNIT (CLINIC/NURSING HOME)
02 CONSTITUTION OF THE UNIT PROPRIETORSHIP/PARTNERSIP/PVT. LIMITED CO./PUBLIC LTD CO./TRUST
03 NAME OF THE KEY PROMOTERS/ PARTNERS/ DIRECTORS / TRUSTEES
04 ADDRESS OF THE UNIT
05 DETAILS OF REGISTRATION NO. OF MEDICAL PRACTIONER
06 DESCRIPTION OF ACTIVITY
WHETHER GENERAL OR SPECILIATY CLINIC
07 SALES TAX /PROFESSIONAL TAX/SERVICE TAX REGD.NUMBER, IF ANY
08 DATE OF ESTABLISHMENT
09 DATE OF LAST RECONSTITUTION
10 DETAILS OF ASSOCIATE /ALLIED CONCERNS
Name Bank Credit Facility Asset Classification

11 WHETHER THE PROPRIETOR/PARTNER/DIRECTORS STOOD AS
GUARANTOR. IF SO DETAILS
On whose Behalf Total Commitment

12 FINACIAL DETAILS
Particulars Last Year Current Year Next Year
Sales
Purchases
Operating Profit
Net Profit
Net Worth
Total Current Asset
Total Current Liabilities
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CENT-DOCTOR

13 REASONS FOR SEEKING FINANCE

14 PROJECT DETAILS
PROJECT ITEMS COST OF ITEM (RS.) MEANS OF FINANCE AMOUNT
(RS.)
LAND PROMOTERS EQUITY
BUILDING BANK LOAN
MACHINERY
/EQUIPMENTS LOAN FROM FRIENDS/RELATIVES
FURNITURES/
FIXTURES LOAN FROM ANY OTHER SOURCE
OTHERS OTHERS
TOTAL TOTAL
15 DETAILS OF TIE UP ARRANGEMENT /MARKETING
ARRANGEMENT, IF ANY
I/We submit followings papers/documents in support of my above submission.
(Please mark tick against each )
(i) Financial statements for year 200_ - __ , 200_ - __ and 200¬¬_ - __.

(ii) Project Report/Techno Commercial Report/Cashflow Statement
(iii) Copy of Registration Certificate of Medical Practitioner
(iv) Permission/Approval from Govt./Statutory Body
(v) Pollution Control/ Environmental check document
(vi) Duly authenticated Document of Constitution like copy Partnership Deed, MoA, AoA, Trust Deed as the case may be.
(vii) Sales tax / Income tax Returns/ assessment orders.
(viii) Original Title Deeds of the property to be mortgaged.
(ix) Valuation report from approved valuer.
(x) Guarantors Consent Letter.

Place: Signature of the Applicant

Date: Signature of the Joint-Applicant

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