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Industry Name: Name of HCE : *	(max 50 characters)
Industry Type:* Type Of HCE:*
Category:*
Specialization *:
Extra Facilities if Any *:	Pathological Laboratory Clinic Blood Test Dispensary Any other
Industry Status: * HCE Status: *	(select current status)
Commissioning Month/Year:
Industry OR HCE Registration/ License No.:	(registration.Date ) (reg.address max 40 char )
Capital Investment of Plant & Machinery:* No. of Beds* No. of Patients* No. of Samples* No. of Animals* No. of Patients*	(Number only) (in Lakhs)
Total Investment(Fixed Assets + Current Assets - Current Liabilities):* No. of Patients	(Number only) (in Lakhs)
Industry Address:* Address:*
Plot No./Khesra NO./ Revenue SurveyNo:	(enter plot number)
Name of Mauza:	(enter Mauza Name)
Khata no.:	(enter khata number)
Place:	(enter village/city of industry locality)
Post Office:	(enter Post Office Name)
District:*	(select district)
Block / Tehsil:*	(enter industry Block)
Pin :	(enter PIN of industry address)
Phone Number:	(STD Code - Number)
Fax No. With Code :	(STD Code - Number)
E-Mail Address :	e.g. info@abc.com
Shifts in Industry :
Whether industry premises declared as prohibited Area:	(Write the name of authority)
Working Seasons per year :	From To
Expected Date of Production :*
No. of workers attending factory per day :*
No. of persons residing in premises:*
Whether Cess Paying :	NO YES Not Applied Yet Last Assessment Upto

Occupier Name:*	(maximum 50 chars)
Designation: :	(designation of occupant)
Address :*	(address, max 100 chars)
Village/City:	(village/city of address)
District:*	(write district)
Post Office:
Pin:*	(PIN of occupant address)
Phone No. With Code:	(STD Code - Number)
Fax No. With Code :	(STD Code - Number)
Mobile No:*	(occupant mobile no)
E-Mail Address:*	e.g. info@abc.com
Status of Applicant:
Name, Address and Telephone of the Chairman/Managing Director/Managing Partner/Owner/Board of Director List (Full Time or Part Time) Other Kinds or Office Bearers are to be Furnished with their Period of Tenures in the Respective Office * : Example:::- Name:-Munish Designation:-Chairman Address:-Lucknow Period Of Tenures:-25/01/2005 To 21/06/2009 Telephone:-123456
Hint Question:*	(select question)
Your Answer:*	(answer of hint question)
Click to generate Password:*	Click here to generate password
Generated Password:*	This is one time password
Document, if any:	(.pdf,.jpg,.jpeg,.gif max of 2MB in size)
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