SERIAL NO.

 NAME:

 Applicant

 Name

 Profession

 Address

 Nursing Home

 Name

 Address

 No. of beds

 Employee

 Total Number

 Category

 Clinical

 Non Clinical

 Date of

 Date of first entry into the register

 Issue of registration

 Renewal of registration

 Registration Number

 Remarks

 Notes

 Cancellation of registration

 Seen and signed by

 Name

 Designation