468 PUNJAB GOVT. GAZ., SEPTEMBER 11, 2020 (BHDR 20, 1942 SAKA) RM “FORM - I {(See rule 10(1) (11) and 12)} APPLICATION FOR REGISTRATION/LICENSE To Director Health and Family Welfare, Punjab, Chandigarh.
Sir, Subject: Application for Registration/ License of
(a) Establishment/ maintenance of Substance Use Disorder Treatment Centre (Indoor Facility), at_________.
(b) Establishment/Maintenance of Substance Use Disorder Treatment Centre integrated facility (de-addiction and rehabilitation):___________
(c) Establishment/ maintenance of Substance Use Disorder Treatment Centre: Outpatient facility, at_________.
(d) Establishment/ maintenance of Substance Use Disorder Counseling and rehabilitation Centre, at___________.
I request you to issue me Registration/License for the period of _______ for the above said institution/s. I am providing the facilities as prescribed by the Act and the rules framed there under. I have attached herewith a Demand Draft for _________/- bearing No………. Dated…….
I hereby give an undertaking to the effect that I shall protect the human rights of the admitted patients and shall not engage in the activities adversely affecting the patients such as solitary confinement, forced labour, punishment, beating, psychological torture, chaining or locked up. The patient's liberty shall be protected at all time. I shall allow private interaction with family and provide communication to the patients under supervision of the authorized person of the centre. I will ensure confidentially of medical and counseling records of the patient, except from the caregivers and under judicial orders.
Thanking you Yours faithfully, Signatures________ Place _____________ Dated: ____________ 469 PUNJAB GOVT. GAZ., SEPTEMBER 11, 2020 (BHDR 20, 1942 SAKA) LM FORM II {(See rule 10(9)} APPLICATION FOR RENEWAL OF REGISTRATION To Director, Health and Family Welfare Punjab, Chandigarh.
Sir, Subject: Renewal of Registration/ License No. ____________ dated ______of
(a) Establishment/ maintenance of Substance Use Disorder Treatment Centre (Indoor Facility), at_________.
(b) Establishment/ maintenance of Substance Use Disorder Treatment Centre Integrated facility (deaddiction and rehabilitation):____________
(c) Establishment/ maintenance of Substance Use Disorder Treatment Centre: Outpatient facility, at_________.
(d) Establishment/ maintenance of Substance Use Disorder Counseling and rehabilitation Centre, at___________.
I request you to renew my Registration/License No. ________ dated the _______ for the next three years from ________ to __________, for the above said institution/s. I am providing the facilities as prescribed by the Act and the rules framed there under. I have attached herewith a Demand Draft for Rs. _________ bearing No.
_______ dated ________ Thanking you Yours faithfully, Signatures_________ Place: ______ Dated: _____ 470 PUNJAB GOVT. GAZ., SEPTEMBER 11, 2020 (BHDR 20, 1942 SAKA) RM FORM III {See rule 10(4), (11) and (12)} REGISTRATION CERTIFICATE We, __________________, being the Licensing Authority under Narcotic Drugs and Psychotropic Substance Act, 1985 (Central Act No. 61 of 1985), after satisfying the requirement of the Substance Use Disorder Treatment Centre indoor facility/ Integrated center/ Outpatient facility , hereby grant the Registration certificate/ licensee for the
(a) Establishment/ maintenance of Substance Use Disorder Treatment Centre (Indoor Facility), at_________.
(b) Establishment/ maintenance of Substance Use Disorder Treatment Centre integrated facility (deaddiction and rehabilitation):_______________
(c) Establishment/ maintenance of Substance Use Disorder Treatment Centre:
Outpatient facility, at_________.
(d) Establishment/ maintenance of Substance Use Disorder Counseling and rehabilitation Centre, at___________.
1. The Registration Certificate/ License shall be valid for a period of three years, commencing from ___________ and ending with _______________. The registration shall be subject to the conditions laid down in the Section 71 of the Narcotic Drugs and Psychotropic Substance Act 1985 and the rules made there under.
Licensing Authority Director, Social Security, Director, Women and Child Welfare Health and Family Welfare, Punjab. Punjab.
Place: __________ Date: ____________ HUSSAN LAL, Principal Secretary to Government of Punjab, Department of Health and Family Welfare.
471 2098/9-2020/Pb. Govt. Press, S.A.S. Nagar