APPLICATION FOR REGISTRATION
OF HEALTHCARE SERVICE PROVIDERS
Healthcare Service Provider is required to complete this form as per the requirements of the
provisions of Punjab Healthcare Commission Act 2010.
Incomplete forms will not be entertained.
Provision of incorrect information/documents will result in rejection of the Application.
Return the completed form to:
Directorate of Licensing & Accreditation,
Punjab Healthcare Commission
th
Office # 1 & 2, 4 Floor Shaheen Complex, 38-Abbot Road,
Lahore
Questions regarding completion of this application may be directed to: Ph. 042 36376371 - 8
For further information, please visit our web site: www.phc.org.pk
A. HEALTHCARE SERVICE PROVIDER
Name: Name of CC Supervisor/Manager, who has got
phlebotomy training certificate from any Govt.
institution or from SKM
CC SUPERVISOR
Designation: _________________________
Qualification (attach copy of degree/diploma): kindly
provide CC Supervisor/Manager qualification details
Status:
Owner
Manager
In-charge
CNIC Number: 34201-0339847-7
Commonwealth MBA Management(AIOU),
CRCP (DUHS)
HHSM (DUHS)CQP (PIQC) MLT (PMF) MLA (PMF)
Registration No. PMDC/ PNC/ NCH/ NCT (attach copy of registration certificate):
if CC Supervisor/Manager has any membership of above mention bodies
Mailing Address:
CC mail address
Town:
SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND LABORATORY
COLLECTION CENTRE BHIMBER ROAD GUJRAT
BHIMBER ROAD
City: GUJRAT
District:
Telephone (landline & mobile)
053-3605473
Fax:
NA
Punjab
Email: cc8.skmch@gmail.com
B. HEALTHCARE ESTABLISHMENT
Name: Shaukat Khanum Laboratory Collection Centre
Date of establishment at present location:
(Day/Month/Year) 01-11-1999
Date of agreement
Previous Name (If any):
N/A
Mailing Address:
CC address
Town:
SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND LABORATORY
COLLECTION CENTRE BHIMBER ROAD GUJRAT
BHIMBER ROAD
Telephone (landline & mobile)
053-3605473
City: GUJRAT
District:
Fax:
Email: cc8.skmch@gmail.com
NA
Punjab
C. TYPE OF ORGANIZATION
Type of Ownership (please check the appropriate box)
FRANCHISE
Government
Others
District Government
Sole Proprietary
Voluntary Non- Profit
Provincial Government*
Partnership
Association
Federal Government
Corporation
Limited Liability Company (Private)
Autonomous Institution
Trust
Limited Liability Company (Public)
CMH/ Cantonment Hospital
If incorporated or registered, date of incorporation/No & organization it is registered with:
*Provincial government includes Social Security, Auqaf department & family planning department etc
D. TYPE OF HEALTHCARE ESTABLISHMENT (please check the relevant box)
Teaching
Non-Teaching
Single Specialty (please specify): _____________________________________________________
Multiple Specialty
Others
GP Clinic/ Homeopath/ Hakim/ Lab/ Radiological or Imaging/Maternity or Nursing homes/
Dental clinic/ Cosmetic Surgery/ Laser Clinic/ If any other please specify: _Collection Centre___
E. BED STRENGTH
Number of Beds: ____N/A________
ATTESTATION
I, the undersigned, do hereby solemnly affirm and declare that the information provided above is
true and correct to the best of my knowledge and belief and that nothing has been concealed
therefrom. I also state that if any false or incorrect information is provided to the Commission, it
may result in rejection of my application for registration and I may also be found liable to pay fine to
the Commission.
Signature to be filled by SKM
Name of Applicant
SYED FARHAN SHAH
Date
Designation
02-04-2015
CC SUPERVISOR
Annexure A: Information Regarding Staff
Training Dates
CC Employee Name
Designation
Contact Number
From Date
SYED FARHAN
SHAH
M RAMZAN
UNFAWAN ULLAH
LATIF
SULMAN SHABEER
SULMAN NAWAZ
MUSHTAQ MASHI
TARA JAVAID
To Date
CC SUPERVISOR
(04-02-2002) TO (08-02-2002)
(28-05-2001)
(01-06-2001)
0343-6245600
PHLEBOTOMIST
(21-06-2002) TO (25-06-2002)
0334-3523273
PHLEBOTOMIST
(30-10-2014) TO (31-10-2014)
PHLEBOTOMIST
CC COURIER
SWEEPER
CC COURIER LHR
0300-6251394
0312-7607636
(23-10-2014) TO (24-10-2014)
0331-6372919
0344-6202592
0321-4228402
