APPLICATION FOR PERMISSION TO ESTABLISH A NEW MEDICAL COLLEGE

Part - I

1. Name of the applicant                      __________________________________________
   (in BLOCK letters)

2. Complete Address with Pin code,
    telephone nos., fax and e-mail           __________________________________________
    (in BLOCK letters)

3. Address of Head Office and                __________________________________________
   Branch Office, if any, with Pin code,
   Telephone nos, telex, fax and e-mail)    _________________________________________

4. Status of applicant whether              __________________________________________
    State Government/Union Territory/
    or University or Trust                       __________________________________________

5. Registration/incorporation                 __________________________________________
   (Number and date, if any)

6. Name and address of Affiliating           __________________________________________
    University

PART I

7. Basic Infrastructure                          __________________________________________
 Facilities available for Medical college
 and attached Hospital                          _________________________________________
 (Attach separate sheet if necessary)

8. Composition of the Trust,                  __________________________________________
Particulars of members of the Society/
Trust, Head or Project Director of the
proposed Medical College, head of the     __________________________________________
existing Hospital, Qualifications
and Experience in the field of Medical      __________________________________________
education of members, Head of Project
or Director and head of the Hospital.       __________________________________________


9. Financial Capability                           __________________________________________
( Balance sheet for the last three years
to be provided if the applicant is a          __________________________________________
Trust. Details of the resources to be
prescribed).                                        __________________________________________

10. Name and Address of the                 __________________________________________
proposed Ayurved/Siddha/
Unani Tibb College

11. Characteristics of proposed site of the Medical College: -

(a) topography                                    __________________________________________

(b) plot size                                        __________________________________________

(c) permissible floor space index             __________________________________________

(d) ground coverage                            __________________________________________

(e) building height                               __________________________________________

(f) road access                                   __________________________________________

(g) availability of public transport           __________________________________________

(h) electric supply                               __________________________________________

(i) water Supply                                  __________________________________________

(j) sewerage connection                       __________________________________________

(k) communication facilities                    _________________________________________

(l) Master Plan of the proposed Medical    _________________________________________
    College

(m) Layout plans, sections                     _________________________________________

(n) elevations and floor wise area            _________________________________________
     calculations

12. Educational Programme

(a) proposed annual intake capacity
of students                                          _________________________________________

(b) mode of admission                            _________________________________________

(c) reservation/preferential allocation
of seats.                                             _________________________________________

13. Functional programme

(a) Department wise and service              _________________________________________
wise functional requirements

(b) Area distribution and room                 _________________________________________
wise sitting capacity.

14. Equipment programme

Department wise list of equipments with year wise schedule of quantities and specifications

a) medical equipments                           _________________________________________

b) scientific equipments                         _________________________________________

c) allied equipments                              _________________________________________

15. Man-power programme

Department wise and year wise provisions-

a) full time teaching staff                       _________________________________________

b) technical staff                                  ________________________________________

c) administrative staff                            ________________________________________

d) ancillary staff                                   _________________________________________

e) salary structure                                _________________________________________

f) mode of payment of salary                  _________________________________________

g) recruitment procedure                       _________________________________________

h) recruitment calendar                         _________________________________________

16. Building programme

a) departments, lecture theatres,           _________________________________________

    examination hall, museum etc             _________________________________________

b) staff quarters                                  _________________________________________

c) staff and students hostels                 _________________________________________

d) administrative office                         _________________________________________

e) library                                            _________________________________________

f) auditorium                                       _________________________________________

g) teaching pharmacy                           _________________________________________

h) mortuary                                        __________________________________________

i) cultural and recreational center           __________________________________________

j) sports complex                                 __________________________________________

k) medicinal plants garden                      _________________________________________

l) Other facilities                                  __________________________________________
(state name of other facilities)

17. Proposed Phase programme and quarter wise schedule of activities indicating -

a) commencement and completion           _________________________________________
of building design

b) local body approvals                          _________________________________________

c) civil construction                              _________________________________________

d) provision of engineering services         _________________________________________
and equipments

e) requirement of staff                         __________________________________________

f) schedule of admission                       __________________________________________

18. Project cost

a) capital cost of land                          __________________________________________

b) buildings                                        __________________________________________

c) plant and machinery                         __________________________________________

d) medical, scientific and allied               __________________________________________
equipments

e) furniture and fixtures                        __________________________________________

f) Preliminary & preoperative expenses    __________________________________________

19. Means of financing the project

a) contribution of the applicant             __________________________________________

b) grants                                          ___________________________________________

c) donations                                      __________________________________________

d) equity                                          ___________________________________________

e) term loans                                     __________________________________________

f) other sources, if any                        __________________________________________

20. Revenue assumptions

a) fee structure                                  __________________________________________

b) hospital user charges                       __________________________________________

c) estimated annual revenue
from various sources                            __________________________________________

21. Expenditure assumptions

a) operating expenses                          __________________________________________

b) depreciation                                    _________________________________________

22. Operating results

a) income statement                             _________________________________________

b) cash flow statement                         __________________________________________

c) projected balance sheets                   _________________________________________

23. Name, address and details of the   _________________________________________
existing hospital

a) bed strength                                    _________________________________________

b) bed distribution, bed occupancy          _________________________________________
and whether a norm of three
in-patients per student would be             _________________________________________
fulfilled.                                                

c) built up area                                    _________________________________________

d) clinical and para clinical disciplines        ________________________________________

e) number of out patient departments
and department wise attendance             ________________________________________

f) architectural and layout plans              ________________________________________

g) list of medical/allied equipments          _________________________________________

h) capacity and configuration of             _________________________________________
engineering services

i) hospital services, administrative          _________________________________________
services, other ancillary and support
services (category wise staff strength)   _________________________________________

Part II

UPGRADATION AND EXPANSION PROGRAMME:

24. Details about the additional             __________________________________________
land for expansion of the
existing hospital                                 __________________________________________

a) land particulars                               __________________________________________

b) location of medical college and
    proposed hospital                           __________________________________________

c) topography                                   __________________________________________

d) plot size                                        _________________________________________

e) permissible floor space index             __________________________________________

f) ground coverage                             __________________________________________

g) building height                                __________________________________________

h) road access                                   __________________________________________

i) availability of public transport             __________________________________________

j) electric supply                                 __________________________________________

k) water Supply                                  __________________________________________

l) sewerage connection                        __________________________________________

m) communication facilities                   __________________________________________

n) Master Plan of the proposed
Medical College                                   __________________________________________

o) Layout plans, sections                      _________________________________________

p) elevations and floor wise area
calculations                                        _________________________________________

25. Upgraded Clinical Programme:-

Year wise details of the additional          __________________________________________
clinical and para clinical activities
envisaged under the expansion              __________________________________________
programme

26. Upgraded functional programme: -

a) specialty wise and service                 _________________________________________
wise functional requirements

b) area distribution                              _________________________________________

c) specialty wise bed distribution           __________________________________________


27. Building expansion programme: -

Year wise additional built-up area to be provided for -

a) departments, lecture theatres,          __________________________________________
examination hall etc

a) hospital                                         __________________________________________

b) staff quarters                                 __________________________________________

c) staff and students hostels                __________________________________________

d) other ancillary buildings                    __________________________________________

28. Planning and Layout: -

Upgraded master plan of the hospital complex along with:-

a) Layout plans                                  __________________________________________

b) Sections                                        __________________________________________

c) Elevations                                      __________________________________________

d) Floor wise area calculation
of the hospital                                    __________________________________________

e) Floor wise area calculation
of ancillary buildings                             _________________________________________

29. Details about up gradation               _________________________________________
or addition in the capacity
and configuration of                             __________________________________________
engineering services and
hospital services                                  _________________________________________

30. Equipment programme:

Upgraded department wise list of equipments with year wise schedule of quantities and specifications -

a) Medical equipments                           ________________________________________

b) scientific equipments                         ________________________________________

c) allied equipments                              ________________________________________

31. Upgraded manpower programme:

Department wise and year wise provisions-

i) full time teaching staff                         ________________________________________

j) technical staff                                    ________________________________________

k) administrative staff                             ________________________________________

l) ancillary staff                                      ________________________________________

m) salary structure                                 ________________________________________

n) mode of payment of salary                   ________________________________________

o) recruitment procedure                         ________________________________________

p) recruitment calendar                           ________________________________________

32. Expansion of scheme - proposed phase programme and quarter wise schedule of activities indicating -

a) commencement and completion             ________________________________________
of building design

b) local body approvals                            ________________________________________

c) civil construction                                ________________________________________

d) provision of engineering and
hospital services                                    ________________________________________

e) provision of medical and
allied equipments                                    ________________________________________

f) requirement of staff                             ________________________________________

g) schedule of admission                          _______________________________________

33. Project cost

a) capital cost of land                             _______________________________________

b) buildings                                           ________________________________________

c) plant and machinery                            ________________________________________

d) medical, scientific and allied                  ________________________________________
equipments

e) furniture and fixtures                           ________________________________________

f) preliminary & preoperative expenses        ________________________________________

34. Means of financing the project :-

a) contribution of the applicant                  _______________________________________

b) grants                                               _______________________________________

c) donations                                          ________________________________________

d) equity                                              ________________________________________

e) term loans                                         ________________________________________

f) other sources, if any                            _______________________________________

35. Revenue assumptions

a) fee structure                                      _______________________________________

b) hospital user charges                           _______________________________________

c) estimated annual revenue
from various sources                                _______________________________________

36. Expenditure assumptions

a) operating expenses                               ______________________________________

b) depreciation                                         ______________________________________

37. Operating results

a) income statement                                  ______________________________________

b) cash flow statement                               _____________________________________

c) projected balance sheets                         _____________________________________

                                                                         SIGNATURE OF APPLICANT

List of enclosures:

1. Certified copy of Bye Laws/Memorandum and Articles of Association/Trust deed.

2. Certified copy of certificate of registration/incorporation.

3. Annual reports and Audited Balance sheets for the last three years.

4. Certified copy of the title deeds of the total available land as proof of ownership.

5. Certified copy of zoning plans of the available sites indicating their land use.

6. Proof of ownership of existing hospital

7. Certified copy of the 'No Objection Certificate' issued by the respective State Government/Union Territory Administration.

8. Certified copy of the consent of affiliation issued by a recognized University.

9. Authorization letter addressed to the bankers of the applicant authorizing the Central Government/Central Council of Indian Medicine to make independent enquiries regarding the financial track record of the applicant.

10. Other enclosures as per the various parts of applications (Please indicate details).

NOTE:   All the copies shall be attested by a gazetted officer.