Service Description
Application Form
Apply For Service
FORM-A
[See rules 4(1) and rule 8(1)]
Application form for Registration of a Genetic Counselling Center / Genetic Laboratory / Genetic Clinic / Ultrasound Clinic / Imaging Center
Section
UBIN
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Select Office
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BAKSA
BARPETA
Biswanath
BONGAIGAON
CACHAR
CHARAIDEO
CHIRANG
DARRANG
DHEMAJI
DHUBRI
DIBRUGARH
DIMA HASAO
GOALPARA
GOLAGHAT
HAILAKANDI
HOJAI
JORHAT
KAMRUP
KAMRUP METRO
KARBI ANGLONG
KARIMGANJ
KOKRAJHAR
LAKHIMPUR
MAJULI
MARIGAON
NAGAON
NALBARI
SIVASAGAR
SONITPUR
SOUTH SALMARA MANCACHAR
TINSUKIA
UDALGURI
WEST KARBI ANGLONG
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Section
1.Name of the Applicant ( Indicate name of the organization sought to be registered)
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2.Address of the Applicant
Address Line 1
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Address Line 2
Address Line 3
Country
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Please Select
India
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Central African Republic
Cape Verde
Chad
Chile
China
Colombia
Comoros
Conga
Costa Rica
Côte d Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Korea,Democratic People s Republic of
Congo, the Democratic Republic of the
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Thailand
The former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United Republic of Tanzania
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Yemen
Zambia
Zimbabwe
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State
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ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN AND DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU AND KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
ODISHA
PUDUCHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTARAKHAND
UTTAR PRADESH
WEST BENGAL
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District
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Postal / Zip Code
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3.Type of facility to be registered
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Genetic Counselling Center
Genetic Laboratory
Genetic Clinic
Ultra Sound Clinic
Imaging Center
Echo Cardiography Clinic
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4. Full name and address/addresses of Genetic Counselling Centre/ Genetic Laboratory/ Genetic Clinic/ Ultrasound Clinic/ Imaging Centre with Telephone/ Fax number(s)/Telegraphic/Telex/ e-mail address(es).
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5. Type of ownership of Organisation (individual/ownership/partnership/company/ co-operative/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 persons responsible for management, as enclosure.
6.Type of Institution
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Govt. Hospital
Municipal Hospital
Public Hospital
Private Hospital
Private Nursing Home
Private Clinic
Private Laboratory
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Others
7.Specific Pre-natal diagnostic procedures / tests for which approval is sought (a)Invasive i)aminocentesis /chorionic villi aspiration / chromo somal/biochemical/ molecular studies
7(b) Non-Invasive Ultrasonography Leave blank if registration is sought for Genetic Counselling Centre only.
8. Equipment available with the make and model of each equipment. (List to be attached on a separate sheet).
9. (a) Facilities available in the Counselling Centre.
9(b) Whether facilities are or would be available in the Laboratory/Clinic for the following tests: (i) Ultrasound (i) Amniocentesis (i) Chorionic villi aspiration Kdooso (a) (v) Foetal biopsy (vi) Cordocentesis
9(c) Whether facilities are available in the Laboratory, Clinic for the following: (i) Chromosomal studies (ii) Biochemical studies (iii) Molecular studies (iv) Preimplantation gender diagnosis
10. Names, qualifications, experience and registration number of employees (may be furnished as an enclosure)
11. State whether the Genetic Counselling Centre/ Genetic Laboratory/ Genetic Clinic/ ultrasound clinic/imaging centre' qualifies for registration in terms of requirements laid down in Rule 3
12. For renewal applications only: (a) Registration No.
12(b) Date of issue and date of expiry of existing certificate of registration.
13. List of Enclosures: (Please attach a list of enclosures/ supporting documents attached to this application)
Applicant details for notifications
Applicant Full Name :
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Mobile Number :
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EMail id :
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