Centre Registration

Complete the form carefully. All required information helps us verify your centre faster.

1. Centre Information

Centre Name *

Centre Address *

City *

State *

Pincode *

Contact Number *

Email ID *

Applicant Full Name *

Role *

Mobile Number *

Email Address

ID Proof Type *

ID Proof Upload *

Separate Collection Room?

Yes No

Refrigerator Available?

Yes No

Bio-medical Waste Disposal?

Yes No

Centre Photographs

No. of Phlebotomists

Training Certificates Available?

Yes No

Upload Certificates

Bank Name *

Account Number *

IFSC Code *

Cancelled Cheque

I confirm all information provided is accurate.

Applicant Name

Date

Signature Upload