Digital Doctor Clinic

Confidential

This application does not obligate either party in any manner.

Applicant’s Name *

Yes, I am interested in becoming a franchisee for The Digital Doctor Clinic & Hospital. I am pleased to provide the following details:

Name ( Dr / Mr / Ms) *

Date of Birth*

Marital Status *

Spouse’s Name (If Married)

Business Address *

Phone (Business) *

Phone (Home) *

Phone (Mobile) *

E-mail *

Fax Number*

( Please attach your visiting card with the form. )

Allowed JPG, GIF or PNG. Max size of 2MB

Cities and the preferred location (if any) in which I would like to start The Digital Doctor Clinic & Hospital (in order of preference) :

1:Location *

2:Location *

3:Location *

Please describe the reasons for choice of cities (including reasons like business connections, family connections, market potential, etc. ) :

Academic Profile

Graduate *

Post Graduate *

Other ( please specify) *

Professional / Business Experience

(Please give details of 3 main ones)

Organization

Activities

Nature of Involvement

Period

Annual Turnover

How do you propose to fund the Project?

Own Funds

Amount (in Rs Lakhs)

Already available. To be arranged in

weeks.

Borrowed Funds

Amount (in Rs Lakhs)

To be arranged in

weeks.

Have you ever been involved in a franchised business? If so, please provide details.

Would you be managing the clinic yourself?* Yes No

What expectations do you have from this business?

Are you related by blood or marriage to any employee/ consultant with the Digital Doctor Clinic & Hospital obdu Group? If so, please give details.

How did you come to know about us ? (Check one)

Advertisement* Other*

Doctors for Professionals

If you are a doctor and you already have a hospital If yes, please provide details.

What is the name of the hospital/clinic?

How many beds does the hospital have?

What is the size of the hospital building?

Mention the names of the main equipment’s/ Machinery of the hospital.

Name of Equipment’s/ Machinery

Month/Year of purchase

Purchase Amount

References (other than relatives)

Name

Profession

Phone No.

Years Known

I submit the above information is true to the best of my knowledge. I understand that Digital Doctor Clinic & Hospital (Obdu Digital Health Care Private Limited ) is relying upon all the above information as a material factor in considering my application to become a franchisee for The Digital Doctor Clinic & Hospital. I agree to supply additional information and statements from my professional associates, as and when required.

Date

Place

Signature:

The information provided should be adequate and complete in all respects, to facilitate the selection process. (You may use additional sheets, if required).

Hospital Register Form