CPQ ID: Fr Office Use Only Date Submitted: Initial Applicatin Frm - Nn Clinical Facility All fields marked with in this applicatin frm are mandatry fields. CPQ will nt accept any applicatin which des nt have these mandatry fields cmpleted. All relevant sectins f this applicatin frm shall be cmpleted including supprting dcuments where indicated and the Declaratin and Signature. Fr any changes t this applicatin (e.g. prpsed services, space r ther) please submit a new applicatin Particulars f the Applicant (wner/tenant f prpsed facility and/ r main sharehlder) Prvide passprt cpy attached t this applicatin Name (as shwn in the passprt (include title)) Address Pstal Cde (ZIP) P.O. Bx City Cuntry Landline Fax Mbile Email 1 Email 2 Prvide passprt cpy attached t this applicatin Name (as shwn in the passprt (include title)) Particulars f the Facility Manager (Where different t the Applicant) Address Pstal Cde (ZIP) P.O. Bx City Cuntry Landline Fax Mbile Email 1 Email 2 Particulars f the Assigned Cntact Persn (Where different t the Applicant) Prvide passprt cpy attached t this applicatin Name (as shwn in the passprt (include title)) Address Pstal Cde (ZIP) P.O. Bx City Cuntry Landline Fax Mbile Email 1 Email 2 Page 1 Nn Clinical Applicatin Frm 2014
Prvide passprt cpy attached t this applicatin Name (as shwn in the passprt (include title)) Address Particulars f Other Representatives 1 (Directr 1- as applicable) Pstal Cde (ZIP) P.O. Bx City Cuntry Landline Fax Mbile Email Prvide passprt cpy attached t this applicatin Name (as shwn in the passprt (include title)) Particulars f Other Sharehlders 2 (Directr 2- as applicable) Address Pstal Cde (ZIP) P.O. Bx City Cuntry Landline Fax Mbile Email Particulars f Premises Prpsed Operatinal Names (Prvide 3 ptins in the rder f preference - name ptins are subject t availability and validatin) 1 2 3 Prpsed Lcatin (including building, flr and unit number) Prpsed Space (in sq ft) Facility Legal Status Free Zne Limited Liability Cmpany (FZ-LLC) Branch f a UAE registered Cmpany Branch f a Freign registered Cmpany Develper Prpsed Segments Nte : Fr selected business segments - refer t current DHCC Decisin 1 Dcument Cncerning Cmmercial License Categries and the 'Certain Restrictins and Requirements' sectin f this frm Healthcare Supprt Healthcare Management Healthcare Cnsultancy Higher Educatin Prvider Page 2 Nn Clinical Applicatin Frm 2014
Prpsed Segments Prfessinal and Management Develpment Training Child Skills Develpment Training Technical and Occupatinal Skills Research and Develpment Educatin Service Prvider Academic Service Prvider Nn Academic Service Prvider Event Management Publishing Executive Search Outsurce Assciatin (Nn Prfit) Service Prvider Reginal Headquarters Htel and Leisure Services Prperty Management Services Prpsed Activities Nte : Only ne activity can be selected per segment except fr segments ' Prfessinal and Management Develpment Training' and 'Events Management' where up t three activities are allwed. Healthcare Supprt Medical Transcriptin Services Medical Billing Services Medical Cding Services Patient Educatin Services Third Party Administratr Healthcare Management Healthcare Management Healthcare Investment Management Healthcare Cnsultancy Healthcare Architectural and Engineering Cnsultancy Healthcare Management Cnsultancy Healthcare Perfrmance Management Cnsultancy Healthcare Strategy and Planning Cnsultancy Healthcare Safety, Quality and Cmpliance Cnsultancy Healthcare Medic-Legal Cnsultancy Healthcare Risk Management Cnsultancy IT Management and Systems Integratin Cnsultancy Clinical Research Organizatin (CRO) Accrediting Qualificatins Organizatin Higher Educatin Prvider University (MOHE Licensed and Accredited) Branch University Junir Cllege Career and Technical Educatin Prvider Prfessinal and Management Develpment Training Cntinuing Prfessinal Develpment Educatrs Prfessinal Develpment Scial and Behaviural Training Human Resurces Training and Develpment Management Training Page 3 Nn Clinical Applicatin Frm 2014
Child Skills Develpment Training Child Skills Develpment Centre Technical and Occupatinal Skills Hspitality and Turism Training Hair Stylist Training Beauty Care Training Health Care Awareness Training Research and Develpment Research and Develpment Centre Educatin Service Prvider Academic Supprt Services Student Supprt Services Academic Service Prvider Academic Liaisn Office University Representative Office Nn-Academic Service Prvider Infrastructure Prvider Segment - Event Management Business Events Management Exhibitin Organizatin and Management Festival Organizatin and Management Publishing Magazines Bks Directrs, Guides, Manuals and Catalgues Executive Search Executive Search Outsurce Operatins Supprt Assciatin (Nn Prfit) Prfessinal Assciatin GENERAL SEGMENT ACTIVITES Service Prvider All activities in this segment must be a branch f a nn free zne UAE Cmpany Accidents and Liabilities Insurance Insurance Agent Insurance Brkers Curier Services Travel Agency Tur Services Car Rental Recruitment Agency Cmputer and Electrnic Accessries Telephne Accessries Digital Printing and Cpying Statinery Kisk Restaurant Page 4 Nn Clinical Applicatin Frm 2014
Service Prvider Cffee Shp Cafeteria Ice-Cream Shp Bread and Bakery Catering Services Pharmacy Optical Centre Health Club/Fitness Centre Theatre and Cinema Beauty Saln (Men) Beauty Saln (Ladies) Early Learning Centre (Nursery) Bk Stre Cmmercial Library Music and Vide Flwer Shp Specialty Stre Cnvenience Stre Supermarket Hypermarket Cmmercial Bank Credit and Finance Bank Bank Liaisn Officer Debt Cllecting Banking Services Mney Exchangers Pht Shp Laundry Gvernment Relatins Dcuments Clearing Services Dcuments and Data Verificatin Services Publishing Distributin Agency Facilities Management Services Car Washing and Cleaning General Maintenance Interir Decratin Landscaping Wrks Structural Quantity Surveying Services Prmtinal Gifts Preparatin Gents Tailring Ladies Tailring Ready-Made Garments Jewellery Stre Perfumes and Csmetics Shp Electrnics Stre Light Fitting and Fixture Shp Valet Parking Services Art Gallery Ship Chandlers Page 5 Nn Clinical Applicatin Frm 2014
Service Prvider Weight Management Nutritinal Prducts Stre Health Equipment and Furniture Stre Cnsultancy Legal Cnsultants - branch nly Lawyers and Advcates - branch nly Auditing f Accunts - branch nly Accunting and Bk Keeping - branch nly Architectural Cnsultancy - branch nly Engineering Design Cnsultancy - branch nly Master-planning and Infrastructure Design Cnsultancy - branch nly Management Cnsultancy Prject Management Cnsultancy Market Research Cnsultancy Interir Design Cnsultancy Hspitality Cnsultancy Branding and Prmtin Cnsultancy Spa Supprt Cnsultancy Reginal Head Quarters Marketing Office Representative Office Call Centre Administrative Office Back Office Htel and Leisure Services Htel - Administratin Office Htel Apartment - Administrative Office Htel Htel Apartment Guest Huse Hspitality Management and Cnsultancy Prperty Management Services Administratin Office Healthcare Develper Cmmercial Develper Residential Develper Others 1 2 3 4 Supprting Dcuments Check List Business Plan (please request template frm CPQ/DHCC) CV's f Management Team Passprt Cpies (refer t sectins fr Applicant particulars) Annual Reprt f previus peratins if applicable Where the sharehlder is a registered cmpany prvide a cpy f the Certificate f Incrpratin frm the Parent Cmpany Page 6 Nn Clinical Applicatin Frm 2014
Restrictins and Requirements The fllwing activities are restricted t persns r rganisatins that are currently licensed t undertake that precise activity by the relevant authrity elsewhere in the UAE, and utside f ther free znes: - All Activities under the Segment Service Prvider - Legal Cnsultants - Lawyers and Advcates - Auditing f Accunts - Accunting and Bkkeeping - Architectural Cnsultancy - Engineering Design Cnsultancy and - Master Planning and/r Infrastructure Design Cnsultancy. The fllwing activities under the Segment Service Prvider are subject t btaining apprpriate apprvals frm Dubai Municipality: - Restaurant - Cffee Shp - Cafeteria - Ice Cream Shp - Bread and Bakery - Catering Services - Health Club/Fitness Centre - Beauty Saln (Men)/ Beauty Saln (Ladies) - Spa Club - Early Learning Centre (Nursery) - Cnvenience Stre - Supermarket/Hypermarket - Laundry - Weight Management - Nutritinal Prduct Stre The transfer f shares in any FZ-LLC cmpany licensed in DHCC is nt allwed fr the first year f incrpratin Fr the General Segments nly ne activity can be licensed and undertaken unless an applicant is specifically authrized frm CPQ t cnduct mre than ne activity. Applicatins under the activity Early Learning Centre (Nursery) shall require the apprval f the KHDA and/r Ministry f Scial Affairs prir t perating. Applicatins under the activities Legal Cnsultant and/r Lawyers and Advcates shall require the apprval f the Dubai Legal Affairs Department prir t perating. Applicatins under Segments Prfessinal and Management Develpment Training, Child Skills Develpment Training, and Technical and Occupatinal Skills shall require a N Objectin Certificate frm the KHDA prir t perating. Applicatins under the Segment Prperty Management Services must btain a N Objectin Certificate frm the Real Estate Regulatry Authrity (RERA) prir t perating. Applicatins under the Segment Htels and Leisure Services is subject t btaining a classificatin frm the Department f Turism and Cmmerce Marketing Applicatins under the Segment Assciatin (Nn- Prfit) must be bna fide representatives f the relevant segment that perates n a nn-prfit and nn-cmmercial basis. Legal status can be either an FZ-LLC r Branch Fr the segment Higher Educatin Prvider refer t DHCC Decisin 1 Cncerning Cmmercial Licensing Categries in DHCC fr requirements - Fr the segment Prperty Management Services refer t DHCC Decisin 1 Cncerning Cmmercial Licensing Categries in DHCC fr requirements - Cmmercial Licensing Fees Where an applicant selects mre than ne segment n this frm this will be subject t additinal licensing fees fr each additinal segment. Refer t DHCC Decisin 1 Cncerning Cmmercial Licensing Categries in DHCC fr fee schedules Space Desk Space is limited t activities under the fllwing Segments nly: - Healthcare Cnsultancy - Healthcare Supprt - Events Management - Cnsultancy - Healthcare Management Page 7 Nn Clinical Applicatin Frm 2014
Applicant Cmments Declaratin and Signature I declare that I am authrized t represent the applicant in this request t perate a facility prpsed in this applicatin I have read all f the requirements listed in this applicatin and the attached fee schedule. I understand that the applicatin fee nce paid is nn-refundable and that the fee schedule may change withut prir ntice. I understand that apprval f the permit is dependent n satisfactry cmpliance with the relevant CPQ/DHCC Departments including Registratin and Licensing fr btaining a Cmmercial License and leasing. I have read all f the requirements relating t btaining a cmmercial license in DHCC frm DHCC's Decisin 1 Cncerning Cmmercial Licensing Categries and understand hw these apply t this applicatin I declare the infrmatin in my applicatin t be true, t the best f my knwledge. I understand that CPQ will cntact me if additinal infrmatin is required t cmplete my applicatin. I am aware that I must authrize any additinal cntact fr this applicatin withut which CPQ will nt release any infrmatin. I declare there are n existing r pending litigatin matters, claims, penalties, prceedings r investigatins by any prfessinal bdy against any prfessinal currently wrking at my existing facility r facilities. I understand that any fraudulent, misleading, deceptive r incrrect infrmatin prvided will result in any apprval issued being revked. Further, any payments made fr the purpse f that apprval will nt be refunded. CPQ reserves the right t refuse, at its sle discretin, any applicatin. Signature Date Page 8 Nn Clinical Applicatin Frm 2014