Application Form – Ayush Quality Mark for Wellness Centres

1. Name of Wellness Centre* (Complete name as mentioned in document establishing the entity)

2. Address of Wellness Centre (Complete address of Premises with City, Pin Code & State/U.T., Country) Address*

3. Address of Regd. Office / Office (if different from 2 above) (Complete address with City, Pin Code & State/U.T., Country) Address*

4. Other location(s) of the centre where also wellness activities are carried out (Separate applications need to be submitted for each such location for recognition)

5. Contact Details of the Centre (Give Telephone No., Mobile Nos., Email Id)

6. Type of Organization & Legal Identity* (Proprietorship, Partnership, Ltd. Pvt. Ltd., LLP, Govt., PSU etc.)

7. Scale of Organization (Large / MSME) a) Large / MSME* Select Large MSME b) In case of MSME, mention Udhyam / other relevant Registration Nos. & Date

8. Details of Registration under clinical establishment act and state act as applicable

Minimum Pdf Size to 2 MB

9. Year of starting / functioning of Ayush wellness centre (Mention name of the authority and authorization / approval / permission / license No. & Date)

10. Management of Organization* (Name & Designation of Top Management & Key Functionaries)

11. Personnel employed (Managerial, Medical professionals, Allied healthcare workers, part time workers, contractual personnel, volunteers and others)

12. Ayush specialties / Therapies covered (Give complete list with Name, Types/variety, as applicable under Ayush)

13. Ayush Products used in pharmacy (Compliant with WHO GMP guidelines on Herbal raw material/Herbal substance and finished products for both prescription and use in therapies)

14. Support services (Ayush pharmacy, Yoga, Physiotherapy, Catering, Housekeeping, Waste Management, Equipment Management and others – specify whether in-house or outsourced)

15. Whether Organization has in-house laboratory for medical testing* Select Yes No

16. Policies in place for admission, treatment, discharge and other policies as per regulations

17. Policies in place to monitor clinical processes and outcomes as part of quality improvement

18. Customer Data (Past 2 years – Period and number of customers)

19. Do you provide overnight stay at your centre for convenience* Select Yes No

20. Document(s) in support of accreditation / certification (Certificate no. & date, name of accreditation/certification body, date(s) of audit, Name(s) of auditor(s), Manday(s) of audit)

Minimum Pdf Size to 2 MB

21. Name and address of consulting agency / consultant engaged (If any, for establishment of system as per standards)

22. Payment of Application Fees (Mode of Payment, Txn Id, Payment Date, Cheque No & Bank etc.)

23. Any other Information (Additional information relevant to the application)

24. Declaration –

It is hereby declared that the information, as provided above are true and the documents attached in support of the application pertain to us and are authentic. I undertake to inform AYUSHEXCIL, in case there is status change in respect of any information or the attached document.

* Application to be signed by Proprietor, Partner, Managing Director, Director, CEO etc. or in his absence, by his authorized representative