Annexure – A

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Annexure :B

Installation completion Certificate cum Detail Sheet of Equipment

( This certificate is to be signed by end user/doctor/technical person/HOD/BME/store keeper and should be maintained by Hospital )

(1)  Name of Hospital : ______

(2)  Department : ______

(3)  Purchase Order No. & Date : ______

(4)  Name of Equipment : ______

(5)  Model No. : ______

(6)  Sr. No. of Equipment : ______

(7)  UNI (Unique no. of Equipment) of Hospital : ______

(8)  Supplier/Manufacture Name& Contact No. : ______

(9)  Received From(GMSCL/Program/Donation): ______

(10)  Transfer From:(If applicable): ______

(11)  Date of Received : ______

(12)  Date of Installation : ______

(13)  Dead Stock Register Page No. : ______

(14)  Warranty Duration: 12/24/36/48/60(Months): ______

(15)  Equipment as per Specification : Yes No

(16)  Training Received during installation : Yes No

(17)  AT (Acceptance Tender) / RC (Rate Contract) copy received : Yes No

(18)  Grant/Funding Source:______

(19)  Type of Payment: In Rs. Foreign Currency

(20)  If Payment is to be done through your institute than Payment is done or not?

Yes No N.A.

(21)  If Payment is to be done through GMSCL than Original Certified Bill is sent to GMSCL or not? Yes No N.A.

The above Equipment is installation and checked according to specification give in purchase order and equipment is satisfactory installed and working and is noted in our deadstock Register No. with page no. and further details of equipment would be maintained by the Hospital as per Annexure : C

Name of user :
Contact No. :
Sign. : / Name HOD:
Contact No. :
Sign. : / Medical Equipment Coordinator :
Contact No. :
Sign. :

Head of Institute

Sign. :

Stamp. :

Annexure – C

Service Satisfaction Certificate

( This certificate is to be signed by end user/doctor/technical person/HOD/BME/store keeper and should be maintained year wise by Hospital )

(During Warranty / CMC )

Equipment under warranty or CMC : ______

(1)  Purchase Order No. & Date : ______

(2)  Name of Equipment : ______

(3)  Model No. : ______

(4)  Sr. No. of Equipment : ______

(5)  UNI (Unique no. of Equipment) of Hospital : ______

(6)  Supplier / Manufacture Name & Contact No. : ______

(7)  Date of Installation : ______

(8)  No. of test details of usage of Equipment : ______

(9)  CMC done by (Local / GMSCL) : ______(if under CMC)

(10)  Service provider / Maintenance Contact No. / Address : ______

(11)  No. of Year of Warranty / CMC : _____ year

(12)  Period of Warranty / CMC : ______to ______

Free Preventive Maintenance Services Details during Warranty / CMC :

Sr. No. / Services Number / Date of Service / Service Engineer contact and contact number / Hospital authorized person sign / Remarks
1
2
3
4

Other break down details:

This is to certify that above given Information related service of Equipment during warranty has been given by company & all service recorded / Report is maintenance by Hospital.

Name of user :
Contact No. :
Sign. : / Name HOD:
Contact No. :
Sign. : / Medical Equipment Coordinator :
Contact No. :
Sign. :

Head of Institute

Sign. :

Stamp. :


Annexure – E

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