SCHEDULE - I FORM NO. V REGISTRATION OF SERVICE PROVIDER Under Section 37 (2) (g) of the Act 1. NAME OF THE ASSOCIATION/SOCIETY/COMPANY --------------- --------------------- 2. WHETHER REGISTERED YES/NO 3. WHETHER COPY OF REGISTRATION CERTIFICATE ENCLOSED ---------------------------------- 4. DATE OF REGISTRATION ------------------------------------- 5. WHETHER AUDITED ANNUAL STATEMENTS/BALANCE SHEET FOR THE LAST 3 YEARS ENCLOSED -------------------------------------- 6. SOURCE OF FUNDING -------------------------------------- 7. BREIF DETAILS OF SERVICE PROVIDED 1. MEDICAL 2. LEGAL AID 3. COUNSELLING 4. SHELTER HOMES 5. OTHER (Specified) 8. BRIEF DETAILS ON NATURE OF WORK ------------------------------------------ -------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- 9. WHETHER PREVIOUSLY WORKED FOR THE STATE CENTRAL GOVT OR ANY AUTHORITY UNDER THE STATE OR CENTRE (DETAILS THEREOF) Signature of the authorized signatory (i) Date of receipt of application (ii) Whether eligible Yes ….No …. (III) Inspection report of the premises/facility whether enclosed (iii) Date of registration under the Act Signature of the Protection Officer Address |