Application Form for NABH MITRA Empanelment Programme (MEP)

Note -

Please fill data in all the fields.

Upload documents in PDF/JPEG/PNG format only. File size should be less than 5mb

Use hyphen (-) in file names (example: name-certificate.pdf). If not able to submit the form, please rename files again using space in file name.

Maximum 500 characters allowed in each field.

All applicants must attach mandatory enclosures as per checklist.

Upload documents after filling all the fields.

Category of Application:

Organisational MITRA
Individual MITRA * Required

About Organistion

Name of the Organisation:
* Required
Name of the Head of the Organisation:

* Required

Official Address :

* Required
District :
* Required
City:
* Required
State:
* Required
Pin Code:
* Required

Phone/Mobile:
* Required Enter 10 digits only

Email ID:
* Required

Alternate Email ID:

Type of Legal Entity :
* Required

Date of Establishment/Registration/Incorporation:
* Required

Website (if any):

PAN Number: * Required Invalid PAN Number (e.g., ABCDE1234F)

TAN Number: Invalid TAN Number (e.g., ABCD12345E)

Number of Employees:
Permanent: Required Number of Permanent Must More or Equals to One
Contractual:
Required Number of Contractual Must More or Equals to One

Accreditation/Certification Projects Supported Since Inception :
Accredited :

Yes

* Required
* Required
Certified :

Yes

* Required

* Required

List of HCOs supported (Minimum 3)

Reference Number of Healthcare Organisation (HCO)	Name of Healthcare Organisation (HCO)	Number of Sanctioned Beds	Accreditation/Certification	Duration of Support (From)	Duration of Support (To)	Contact Person (Name)	Contact Person (Designation)	Contact Details (Email)	Contact Details (Phone)	Outcome of the Support Provided	Sample Document	Upload document
* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required Enter 10 digits only	* Required	Download Sample Letter	* Required
* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required Enter 10 digits only	* Required	Download Sample Letter	* Required
* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required	* Required Enter 10 digits only	* Required	Download Sample Letter	* Required

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Nominations for NABH Certified Professionals

Professional 1

Name of the Applicant:
* Required * Required

Designation: * Required

DOB: * Required

Phone: * Required Enter 10 digits only

Email ID: * Required

Proof of Identification /Any Govt. issued ID (Aadhar /Voter ID):
* Required

* Required

Educational Qualification:
* Required * Required
Specialized Degree/Certification (If any):

Total Work Experience after obtaining essential qualification: * Required

Years of Experience of Implementing NABH Standards: * Required

NABH Standards POI attended :

Yes

* Required

Current NABH Assessor :

Yes

* Required

Attach document

Biography: * Required
Photograph: * Required
Educational Qualification: * Required
NABH POI Training:
Signature: * Required
Proof of Identification /Any Govt. issued ID (Aadhar /Voter ID) : * Required

Professional 2

Name of the Applicant:
* Required * Required

Designation: * Required

DOB: * Required

Phone: * Required Enter 10 digits only

Email ID: * Required

Proof of Identification /Any Govt. issued ID (Aadhar /Voter ID):
* Required

* Required

Educational Qualification:
* Required * Required
Specialized Degree/Certification (If any):

Total Work Experience after obtaining essential qualification: * Required

Years of Experience of Implementing NABH Standards: * Required

NABH Standards POI attended :

Yes

* Required

Current NABH Assessor :

Yes

* Required

Attach document

List of Enclosures

☐ Geotagged Photograph of MITRA Organisation Infrastructure * Required
☐ List of MITRA Organisation Employees with Designation * Required

Declaration by Applicant

I hereby declare that the information provided in this application is true and correct to the best of my knowledge .I Understand that providing false or Misleading Information may lead to rejection/cancellation of my application for empanelment as Organisation MITRA.

I agree to abide by all terms and conditions of the NABH MITRA Empanelment Programme , including adherence to the Code of Conduct, maintenance of confidentiality, ethical behavior and avoidance of any conflict of interest in all NABH related activities.

Name and Designation of the Head of the Organisation : * Required

Place : * Required

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Application Form for NABH MITRA Empanelment Programme (MEP)

About Organistion

List of HCOs supported (Minimum 3)

Nominations for NABH Certified Professionals

Professional 1

Attach document

Professional 2

Attach document

Details of Infrastructure of MITRA Organisations

List of Enclosures

Declaration by Applicant