Schedule-2

Schedule-2
(Relating to Sub-rule (1) of Rule 3)
Application for permit to operate kidney transplantation
service
The Organ Transplantation Coordination Committee,
Kathmandu.
Subject: Request for permit
Whereas, I need the permit to operate the kidney transplantation
service;
Now, therefore, I have made this application, accompanied by the  necessary fees, and setting out the following details, for purposes of Section 4 of the Act and Sub-rule (1) of Rule 3 of the Rules.
Applicant health institution’s:
Name:
Address:
Office issuing the health institution registration certificate:
Registration number:
Date of registration:
If the renewal of health institution is required, date of expiration of
term:
A description of such physical means, human resource and other necessary services and facilities as existing in this health institution for providing the organ transplantation service is attached herewith. The above-mentioned contents and the description attached herewith are true and correct, if proved false, I shall bear and pay according to law.
Seal of health institution:
Applicant on behalf of health institution:
Name:
Signature:
Designation:
Date: