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1 Proposal for academic year Registration No. N (For Office use only) Maharashtra University of Health Sciences, Nashik (An ISO 9001:2008 Certified University) Application for expressing interest for establishment of School of MBA Health Care Administration as constituent / conducted college / institute / University Department of MUHS Nashik (Under Section 5(y) and 5(aa) of the Maharashtra University of Health Sciences Act, 1998) The management seeking permission to start School of MBA Health Care Administration shall submit the application in two copies in the prescribed format to the Registrar, Maharashtra University of Health Sciences, Nashik , on or before 07/05/2015. To, The Registrar Maharashtra University of Health Sciences, Mhasrul, Dindori Road, Nashik Sir, I am / we are submitting herewith the application with a request to start School of MBA Health Care Administration from the academic year under Section 5(y) and 5(aa) of the Maharashtra University of Health Sciences Act, ) Name and address of the Society /Institution : PIN code : Phone No.(O) : Fax No. : Applicant s (R) : Address : Mobile No. : / 8

2 2) Name of the proposed School of MBA Health Care Administration & Postal address : PIN code : Phone No.(O) : Fax No. : Address : Mobile No. : 3) Number and date of the Registration of Society / Institution : i) Public Trust Act 1950 : ii) Society s Registration Act 1860 : (Enclose attested copies of Registration, Constitution and Memorandum of Association) 4) The resolution of the Management in respect of start School of MBA Health Care Administration with reference to the provision in the memorandum of the Society / Institute (Enclose copy of the Resolution). No. Dated 5) 7200 Sq. Ft. constructed space. 6) Building : i) Whether the Building / land is owned by the Applicant Society / Trust : Yes / No * a) Lecture Halls : Sq. Ft. each 1400 Sq. Ft. b) Tutorial Room : Sq. Ft. each 800 Sq. Ft. c) Faculty Rooms : Sq. Ft. each 900 Sq. Ft. d) Administrative Staff Rooms : Sq. Ft. each 400 Sq. Ft. e) Library : Sq. Ft Sq. Ft. f) Seminar Room : Sq. Ft Sq. Ft. g) Boys common Room : Sq. Ft. 500 Sq. Ft. h) Girls common Room : Sq. Ft. 500 Sq. Ft. i) Cafeteria : Sq. Ft. 700 Sq. Ft. Total 7200 Sq. Ft. * Lecture Halls shall be shared and should be made available as per requirement of curriculum. 2 / 8

3 7) Teaching Staff for concern subject : a) Director / Professor : 01 b) Associate Professor : 01 c) Assistant Professor : 03 Note : 1 Applicant must obtain the consent of joining of qualified and eligible Teaching Staff on Rs. 100/- Stamp paper duly notarized. 2 The appointment, experience and pay-scale of the Teaching Staff will be as per UGC norms. 8) List of non teaching staff appointed : Attached : Yes / No 9) Allopathic Hospital : (Minimum 100 Beds) Own / Attached * i) Name of the Hospital: ii) Date of Establishment: iii) Date of Registration: (a) As per Bombay Nursing Home Registration Act 1949 (b) Under Shop Act 1948 (Attach a copy of valid Registration certificate) iv) No. of Beds available : Male Female Total v) OPD (No. of Patients per year) : vi) IPD (No. of Patients per year) : vii) No. of wards (Enclose the list separately with bed strength.) viii) Built-up area (If own /attached, submit a drawing plan duly certified by Architect.) ix) Attach list of equipments and infrastructure facilities available : x) List of Para-medical Staff : *Note : 1) In case of attached hospital(s), attach a Memorandum of Understanding between the Trust and owner of the hospital(s) at least for a period of five years on stamp paper of Rs. 100/- (each) duly notarized. 2) The practical facilities for the students should be made available in larger Hospitals. 3 / 8

4 11) Hostel: - Provision for boys hostel: - Yes / No girls hostel :- If Constructed- total built up area : Yes / No Sq. ft. (Attach a certified copy of plan of Hostel building by an Architect) or If not constructed : (Certified copy of drawing plan of proposed building as per Council norms by an Architect) 12) Detailed information regarding the School(s) and College(s) run other than this by the applicant Society / Institution with year of establishment. (Attach separate sheet, if required) 13) Financial position of the Society / Institution as on 31 st March of the Financial Year. Encls: i) Copies of audited statements for last preceding three financial years. ii) Attach latest bank balance certificate. 14) Cash flow statement with budgetary provision to establish the College / Institute for next 5 years. Statement attached : Yes / No I solemnly declare that, information furnished above is true and correct to the best of my knowledge. Place : Signature of the Chairman / Secretary Date : Seal of the Society / Institution Note :- 1) Every page of the application form and enclosures must be serially numbered in the box provided against each column and Index should be given. 2) Please note that incomplete application form will be rejected. 4 / 8

5 FORM OF RESOLUTION Subject :- For permission to start School of MBA Health Care Administration in the subject of from the academic year Resolution :- No..... Dated : In view of the above subject this Management of.. (Name of the Society/Institution/Trust)... in its meeting held on.. resolved unanimously that the Health Sciences College in the subject of. be started at. (Place with address) from the academic year Resolution proposed by Seconded by Date: - Place: - Seal Signature of President / Secretary 5 / 8

6 Consent of Director / Principal (should be submitted on Rs.100/- stamp paper duly notarized) I, the undersigned Dr/Mr./Mrs./Smt. Age. Years. Presently working as Department at.. I herewith give my consent to join as Director / Principal to the proposed College to be setup by. Society / Trust at as and when required. My educational qualifications are as follows:- Sr. No. qualification Name of University Year of Passing subject I will faithfully serve the Institute in this capacity to the best of my ability. Seal of Notary Signature Name in Full Address 6 / 8

7 Undertaking for appointing Teaching staff (should be submitted on Rs.100/- stamp paper duly notarized) I...(name of the president / secretary of the trust/society ) hereby give undertaking that the required teaching staff will be appointed for the..(name of the proposed subject College / Institute) to be established at..(name of the place) as per the norms of..(name of the respective council) and Maharashtra University of Health Sciences, Nashik, at the time of first affiliation. Place : Date : Seal of Notary Signature Name of the President / secretary: 7 / 8

8 Sr. No. CHECK LIST (Please attach papers as per check- list) Documents description 1 Certified copy of Registration of Society / Institution under Public Trust Act, 1950 A 2 Certified copy of Registration of Society / Institution under Society s Registration Act, 1860 B 3 Certified copy of constitution and Memorandum of Association & Copy of Resolution (Original) of C Management 4 Land earmarked for the College (Attach copy of 7/12 extract / property card.) D 5 Certified copy of drawing plan of building / proposed building plan by Architect. E 6 Teaching Staff for concerned subject F 7 Consent of joining of Director / Principal (given on Rs. 100/- stamp paper duly notarized) G 8 List of non-teaching staff appointed H 9 If attached hospital(s), (please attach separate memorandum of understanding (MOU) for each attached Hospital on Rs. 100/- stamp paper duly notarized) 10 Undertaking by President/Chairman of the Applicant Trust regarding provision and maintenance of infrastructure and staff. (given on Rs. 100/- stamp paper duly notarized) 11 Registration of Hospital under Bombay Nursing Home Act, 1949 K 12 Registration of Hospital Under Shop Act 1948 L 13 Hostel M 14 Undertaking regarding correctness of documents submitted about Land, Building, Ownership, Lease etc. (given on Rs. 100/- stamp paper duly notarized) N Write page numbers in the bracket of Page No. Yes/ No Appex Page No. For office use I J C E R T I F I C A T E I hereby certify that papers are attached as per the check list. (N.B. Please note that all documents are mandatory. The application will be rejected if one or more documents in the check list are not attached). Place Date : Seal Chairman / Secretary Signature of Scrutiny Officer of MUHS 8 / 8