APPLICATION FOR GLOCAL DIGITAL DISPENSARY.
required *
A. For Office Use:
Entrepreneur Name:
Location:
B. Business Information:
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Category:
Individual
Group
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Name of the Company/Entrepreneur:
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Name of the Contact Person:
Address:
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Current Business Address:
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City / Town:
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State:
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PIN Code:
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Telephone No:
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Mobile No:
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Business Premises:
Rented
Owned
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Residential Address:
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Email Address:
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Business Activity:
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Date of Commencement:
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Whether the Unit is Registered:
Yes
No
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Registration No. and the Act under which registered:
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Social Category:
General
SC
ST
OBC
Minority Community
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Specific Minority:
-- Select --
Buddhists
Muslims
Christians
Sikhs
Jains
Zoroastrians
Others
C. Background Information:
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Name
Date of birth
Sex
Residential Address with Mobile No.
Academic Qualification
Type of Experience
No of years
Experience in Healthcare(Years)
1
Male
Female
Transgender
D. Identification Information:
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ID Name
*
ID Number
*
Upload
*
1
2
3
E. Banking Facilities Existing:
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Bank Name
Bank Address
Account Type
1
Saving
Current
Add More
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Type of loan
Lender
Amount o/s
1
F. Project Financing Break UP - Proposed:(In Rs.)
Means of finance
for the project
Amount
Type of Investment Cash/FD
Personal loan etc.
Details
Own investment
Or
Bank Loan
G. Property Details for proposed Digital Dispensary:
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Address
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Area(Sqft)
*
Type of Property
*
Period of Agreement(years)
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Facilities
*
1
Own
Rented
Leased
Water
Toilet
Electricity
Internet
H. Amount want to pay:
*
Amount:
I. Reference Details:
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Reference Name:
Contact No:
Documents attached:
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Copy of Ownership/lease/rent document for the premises:
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Copy of last academic qualification:
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Address proof of residence:
Passport:
Driving Licence:
NREGA Card:
SC/ST/OBC certificate: