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Dindori Road, Mhasrul, Nashik – 422 004

Tel : (0253) 2539244, 241,242 / 6659244, 241, 242
Website : www.muhs.ac.in, E-mail : planning@muhs.ac.in

Application to start Certificate Course in Modern Pharmacology (CCMP)

1. The management seeking permission to start Certificate Course in Modern
Pharmacology (CCMP) in the prescribed format to the Registrar, Maharashtra University of
Health Sciences, Nashik – 422 004, for Academic year 2020-21 along with D.D./RTGS/NEFT/
University E-payment Gateway drawn in favour of The Registrar, Maharashtra University of
Health Sciences, Nashik on any Nationalized Bank & payable at Nashik.
2. Please read the instructions carefully before filling the form over writing and correction not
allowed.
________________________________________________________________________________
To,
The Registrar,
Maharashtra University of Health Sciences,
Vani – Dindori Road, Mhasrul,
Nashik 422 004
Sir,
I am / we are submitting herewith the application with a request, under Section 64 (3) of
the Maharashtra University of Health Sciences Act, 1998 to start Certificate Course in
Modern Pharmacology (CCMP) with an Intake Capacity 50 students from the
Academic Year 20…- .....
Following are the particulars:

i) Name of the
Society/Institute/
01 (ii) Name of the Govt/Private
Medical College
iii) Postal Address, with PIN M: , T:
iv) Contact Details:
v) E-mail ID:
Society/Institution/College/ i) Public Trust Act 1950: . . . . . . . . . . . . . . . . . . . .
02 Hospital Registration Number ii) Society’s Registration Act 1860: . . . . . . . . . . .
and date:
iii) Year of establishment: . . . . . . . . . . . . . . . . . . .
iv) Copies of Registration, Constitution and Appendix ‘A’
Memorandum of
Association attached? *Yes/No.
v) Certificate of Registration under Bombay Shop
Act 1948.

(contd page 2/-)

 -2-
i) Name of the College/Institute
where course is to be conducted :

ii) Postal Address, with PIN:

03
iii) Contact Details: M: , T:
iv) E-mail ID:
v) CCMP Coordinator details : Name: M: e-mail:
04 Whether Govt/Private Medical *Yes/No …………………………………………..
College is affiliated to/ recognised MUHS Affiliation/Recognition letter attached?: Appendix ‘B’
by MUHS Nashik? If yes, state *Yes/No.
letter No. & date.
05 Year of Recognition by MCI (UG) Letter No :
(Attach copy) Appendix ‘C’
Date :

06 Fee details:
Appendix ‘D’
(i) Amount Rs…………………………..
(ii) Mode of payment RTGs/NEFT/DD/pay online…….………..dated……….
(iii) DD/NEFT/RTGs Ref or UTR No & date……………….
(iv) Name of the bank & Branch……………………….
(Please attach receipt in case the fees paid by NEFT/RTGs/pay online)
07 Financial position of the Society/ Audited Statements of Accounts for i) 20 . . . - . . ,
Institute in the preceding 03 years: ii) 20 . . . - . . . , iii) 20 . . . - . . . attached? *Yes/No Appendix ‘E’

08 Budgetary provision for the CCMP i) 20 . . . - . . . Rs . . . . . . . . . ., ii) 20 . . . - . . . Rs . . . . . . . . . .

for the next 03 years: iii) 20 . . . - . . . Rs . . . . . . . . .
09 Audio-visual aids: Available? Quantity

i) Slide projector: *Yes/No

ii) 6 mm projector: *Yes/No
iii) LCD Projector: *Yes/No
iv) Overhead projector: *Yes/No
v) Screen: *Yes/No
vi) VSAT Connectivity with CMC Vellore: *Yes/No
10 Research: Department-wise number of Publications List attached? *Yes/No. Appendix ‘F’

11 Teaching Staff
Sr. Name Qualification Experience Approved/Recognised
Appendix ‘G’
No by MUHS

(i) Non teaching staff : List attached ? *Yes/No Appendix ‘H’

(ii) Technical staff : List attached ? *Yes/No Appendix ‘J
12 Library: *Adequate/Inadequate. List of books, journals, e- Appendix ‘K’
i) Books & Journals available in the journals, e-books attached? *Yes/No
Library:
ii) Does the Institution have liaison *Yes/No. If yes, its distance from the Institution/ Appendix ‘L’

with other library (ies)? Hospital: . . kms. ‘Permission Letter’ from the
concerned Library attached? *Yes/No.

(contd page 3/-)

 -3-

13 Building : *Yes/No.
i) Administrative Block:
ii) Class Rooms: *Yes/No.
iii) Hospital Facilities: *Yes/No.
14 Laboratory : i) Affiliation with a *Yes/No. If yes, attach valid Memorandum of Appendix ‘M’
Laboratory/ Radiologists? Understanding.
ii) Research Laboratory *Yes/No. If available, state all details. Appendix ‘N’
available?
iii) Equipments/Instruments List attached? *Yes/No. Appendix ‘P’
available for the conduct of
Course:
15 Hostel: i) Boys: *Yes/No
16 Computer Laboratory: i) Quantity of computers:
ii) Internet facility: *Available/Not Available
iii) Own web site: *Available/Not Available
17 Seminar Hall: Minimum Capacity of 50 *Available/Not Available
Audience
18 Ethical Committee: *Available/Not Available
19 Hospital : Own 300 bedded Hospital *Yes/No.
20 i) Certificate of Registration under Appendix ‘Q’
Bombay Nursing Homes Act 1949.
ii) Letter of Bio-medical Waste Appendix ‘R’
Authorisation/Renewal application of
BMW authorization, issued by
Maharashtra Pollution Control Board
(iii) Built – up area:
iv) OPD/IPD (No. of patients per year): Speciality Paid Free Total

v) Paramedical Staff: List attached? *Yes/No. Appendix ‘S’

vi)Specific Equipments/OT Instruments a) List attached? *Yes/No. Appendix ‘T’

(CT Scan, MRI, ECG, Sonography, X-ray, b) Plan duly certified by the Architect Appendix ‘U’
etc.) attached? *Yes/No.

vii) Valid Letter/Application for Renewal of *Yes/No. Appendix ‘V’

Bio-Medical Waste Authorisation issued
by Maharashtra Pollution Control Board
attached?

I/We solemnly declare that, all the information furnished above is true and correct to the best of my/our
knowledge.

Signature with Stamp Signature with Stamp

Head of Department Head of Institute
Date:
Place:
College/Institute Round Seal: