FORM-A

[see rules 4(1) and 8(1)]

(To be submitted in Dulicate with supporting documents as enclosures)

Application form for Renewal of 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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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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State *

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District

Postal / Zip Code *

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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

any other to be stated

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Other Type of Institution

7.Specific Pre-natal diagnostic procedures / tests for which approval is sought (a)Invasive i)aminocentesis /chorionic villi aspiration / chromosomal/biochemical/ molecular studies

7.(b) Non-Invasive Ultrasonography Leave blank if registration is sought for Genetic Counselling Centre only. (Leave Blank if registration is sought for genetic counselling center 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. *

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(b) Date of issue and date of expiry of existing certificate of registration.

Date of Issue *

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Date of Expiry *

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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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Mail id : *

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