Application Form

APPLICATION FORM

(FOR EMPANELMENT OF DIAGNOSTIC CENTRES)

To,

The Sr. State Medical Commissioner,

Office of State Medical Commissioner

 Employees State Insurance Corporation

143 , Sterling Road , Nungambakkam , Chennai

Subject: Expression of Interest (EOI) for Empanelment for diagnostic services to ESI beneficiaries.

Sir,

We, Dr Venkat Scans & Diagnostic centre, wish to offer diagnostic services to ESI beneficiaries on cashless basis.

We Pledge to abide by the terms and conditions of the tender document and We also certify that the above information as submitted by us in Annexure is correct and We fully understand the consequences of default, if any.

DR VENKATAAPATHY DMRD DNB

MANAGING DIRECTOR

Place: HOSUR

Date: xx.xx.xxxx