COVID 19 RELIEF

Name of Hospital

Type Central Government State Government Semi Government Private Charity

Designated COVID-19 Facility? Yes No

Total Beds

Address

City

Pin Code

Name of Person

Designation

Contact Number

Email

Website

I am authorized to receive the requested supplied on behalf of the hospital.
The received supplies will only be used by the healthcare staff for treatment related to COVID 19 patients in the mentioned hospital.
I also acknowledge that Pramanit Foundation does not bear any responsibility related to the size, quality or specification of the product.