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APPLICATION FOR ADMISSION (COUPLES)

PART A: GENERAL

PART B: FINANCIAL INFORMATION/GUARANTOR’S DETAILS (IF APPLICABLE)

PART C : DETAILS OF NEXT OF KIN/PERSON(S) TO BE CONTACTED IN EMERGENCIES

PART D : DETAILS TO HELP US IN TAKING CARE OF YOU

CLASS OF ADMISSION *COPPERSILVERGOLDPLATINUM

TYPE OF ACCOMODATION *SUITEDORMITORYSEMI-PRIVATEDELUXE Pvt.NIGHTINGALE

Your image *

No file chosen

Co-applicant Name *

Father's/Husband's Name *

Date of Birth *

PAN No.0 / 10

Permanent Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Present Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Telephone/Mobile No *

Email Address *

Educational/Professional Qualifications

Previous Work detailsGovt ServicePrivate ServiceSelf-EmployedBusinessOthers

Details of Last Employer/Position held

Name, Nature of Business/Self-employment

Other Relevant details

Why do you want to Stay at Assisted Living Aastha Pvt. Ltd. Facility?

What are your Hobbies/Interests?

In case you propose to pay yourself, please state your annual income :

In case someone else is guaranteeing payment please furnish the following details:

Name of Guarantor

Relation with Applicant

PAN No.0 / 10

Self-attested Copy of PAN Card

No file chosen

Annual Income of Guarantor

HTML

Permanent Address

Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

HTML

Present Address

Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Telephone/Mobile No *

Email Address

If Granted Admission, how do you or your Guarantor propose to pay the monthly/other charges?

Frequency of advance payments most convenient for you *MonthlyQuarterly (and avail 1% rebate)Half-Yearly (and avail 2.5% rebate)Annually (and avail 5% rebate)

Mode of Payment *CashCheque/CardDemand Draft/Banker’s Cheque/Net BankingBank Transfer through ECS/Standing Instructions

Details of Nearest Relative/Local Person to be contacted for your support in emergencies:

Person 1

Name of Next of Kin/Legal Heir *

Relation with Applicant *

Contact Address

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Telephone/Mobile No *

Email Address *

Person 2

Name of Next of Kin/Legal Heir

Relation with Applicant

Contact Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Telephone/Mobile No

Email Address

Person 3

Name of Next of Kin/Legal Heir

Relation with Applicant

Contact Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Telephone/Mobile No

Email Address

Person 4

Name of Next of Kin/Legal Heir

Relation with Applicant

Contact Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Telephone/Mobile No

Email Address

Do you have any Medical/Health Insurance?YesNo

If yes, attach photocopies with all details

No file chosen

Are you covered under any scheme or any TPA/InsuranceYesNo

If yes, attach photocopies with all details

No file chosen

. In case of Medical Emergencies, where would you like to be treated (please rank in order of preference)?

First

Second

Third

Fourth

Fifth

Please furnish any other information you think is necessary or pertinent for your wellness *

Address List

B-52, Mahanagar Extension, J-Park, Mahanagar, Lucknow, Uttar Pradesh 226006
9415015050
hospiceindia@gmail.com

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