FORM A
[See sub-rule (2) of Rule 4]

Form of application for the approval of a place under clause (b) of Section 4.
1. Name of the place (in capital letters)
2. Address in full
3. Non-Governmental/Private/Nursing home/Other Institutions*.
4. State, if the following facilities are available at the place:
(i) An operation table and instruments for performing abdominal or gynaecological surgery.
(ii) Drugs and parenteral fluid insufficient supply for, emergency cases.
(iii) Anaesthetic equipment, resuscitation equipment and sterilisation equipment.
Signature of the owner of the place
Place:
Date:
* Strike out whichever is not applicable.