Schedule – 4
(Related to Sub-section (2) of Section 5)
Application to be submitted to enlist the name of a Health Institution
To,
The Director General / The Chief
Department of Health / ……………. Health Office.
Subject :– The name of a Health Institution to be enlisted.
I/we have submitted this application to enlist the name of this Health institution
for providing the safe abortion service, pursuant to the Sub-section (2) of
Section (5) of the Safe abortion Service Processes, 2060, mentioning the
following details.
1. Name and Address of the Health Institution :–
2. The office where the Health Institution has been registered :–
3. Registration No. of the Health Institution and Date :–
4. Other services that has been provided by the Health Institution :–
5. Name and surname of chief official of the Health Institution :–
6. While operating the safe abortion service from the Health Institution.
I/we shall follow the provisions mentioned in the No. 28b. of Section on
Homicide of the National Code (Muluki Ain) and these processes.
7. The No. and Date of the letter that has been given to conduct the other
services from the Health Institution :–
8. The last date of monitoring of the Health Institution from the office :–
Date :– Applicant’s,–
Seal of the Health Institution :– Signature :–
Name :–
Designation :–