On approval of the Rules for provision of public service "Issuance of a license for medical activity"

New Unofficial translation

Order of the Minister of Health of the Republic of Kazakhstan dated June 1, 2020 No. ҚР ДСМ -59/2020. Registered in the Ministry of Justice of the Republic of Kazakhstan on June 2, 2020 No. 20809

      Unofficial translation

      In accordance with subparagraph 1) of article 10 of the Law of the Republic of Kazakhstan "On public services", I HEREBY ORDER:

      1. To approve the attached Rules for provision of the public service "Issuance of a license for medical activity".

      2. The Committee for Control of Quality and Safety of Goods and Services of the Ministry of Health of the Republic of Kazakhstan, in accordance with the procedure established by the legislation of the Republic of Kazakhstan, to ensure:

      1) state registration of this order in the Ministry of Justice of the Republic of Kazakhstan;

      2) placement of this order on the official Internet resource of the Ministry of Health of the Republic of Kazakhstan;

      3) within ten working days after state registration in the Ministry of Justice of the Republic of Kazakhstan, submission of information to the Legal Department of the Ministry of Health of the Republic of Kazakhstan on implementation of the measures provided for in subparagraphs 1) and 2) of this paragraph.

      3. The supervising Vice-Minister of Health of the Republic of Kazakhstan is authorized to control the execution of this order.

      4. This order comes into effect upon the expiration of twenty one calendar days after the day of its first official publication.

      Minister of health of the
Republic of Kazakhstan
Ye. Birtanov

      AGREED
Ministry of digital development,
innovations and aero-space industry
of the Republic of Kazakhstan

  Appendix
to the order of the
Minister of health of the
Republic of Kazakhstan
dated June 1, 2020
№ ҚР ДСМ-59/2020

Rules for provision of public service "Issuance of a license for medical activity"

Chapter 1. General provisions

      1. These Rules are developed in accordance with subparagraph 1) of Article 10 of the Law of the Republic of Kazakhstan dated April 15, 2013 "On public services" (hereinafter referred to as the Law) and determine the procedure for rendering the public service "Issuance of a license for medical activity" (hereinafter referred to as the Rules).

      2. The public service "Issuance of a license for medical activity" (hereinafter referred to as the public service) is provided by local executive bodies of regions, cities of republican significance and the capital (hereinafter referred to as the service provider) to individual and legal entities (hereinafter referred to as the service recipients) to carry out medical activity in the territory of the Republic of Kazakhstan.

      3. The application is accepted and the result of the rendered public service is issued through:

      1) Non-profit joint stock company "State Corporation "Government for Citizens" (hereinafter - the State Corporation);

      2) the web portal of the "electronic government" www.egov.kz, www.elicense.kz (hereinafter referred to as the portal).

      The public service is provided at the place of registration of the service recipient in the order of an "electronic" queue, without accelerated service.

      4. The list of basic requirements for provision of public service, including the characteristics of the process, the form, content and result of the provision, as well as other information, taking into account the specifics of provision of a public service, are set out in accordance with Appendix 1 to these Rules.

      5. The result of provision of a public service or a reasoned response about refusal to provide a public service, when the service recipient applies for a license and (or) annex to the license:

      on paper – is issued in electronic form, printed and certified with the seal of the service provider and the signature of the head of the service provider and submitted to the State Corporation;

      through the portal – is issued in electronic form, certified with an electronic digital signature (hereinafter - EDS) of the authorized person of the service provider, is sent to the portal and stored in the "personal account" of the service recipient.

      6. Payment of the license fee, in the amount established by article 554 of the Code of the Republic of Kazakhstan dated December 25, 2017 "On taxes and other obligatory payments to the budget (Tax Code)", is made in cash and non-cash through second-tier banks and organizations that carry out certain types of banking operations, as well as through the payment gateway of the "electronic government" portal (hereinafter - PGEG).

Chapter 2. Procedure for provision of public service "Issuance of a license for medical activity"

      7. The service recipient and (or) employee of the State Corporation from the relevant state information systems through the gateway of the "electronic government" receives information:

      1) on identity documents;

      2) on state registration (re-registration) of the service recipient as a legal entity or individual entrepreneur;

      3) on the presence of a license for medical activity;

      4) certifying the right of ownership, lease or trust management of state property to a premise or building, concluded for a period of more than one year;

      5) on payment of the amount of the license fee (in case of payment through PGEG);

      6) on the registration of the real estate object.

      If the service recipient provides an incomplete package of documents according to the list provided for in paragraph 8 of Appendix 1 to these Rules, the employee of the State Corporation refuses to accept the application and issues a receipt of refusal to accept documents in the form, in accordance with Appendix 2 to these Rules.

      If the service recipient provides an incomplete package of documents through the portal, the service provider prepares a reasoned refusal to further consider the application within two working days.

      When submitting documents:

      to the State Corporation - the service recipient receives a receipt of acceptance of the relevant documents;

      through the "portal" - in the personal account of the service recipient, the status of acceptance of the request for provision of a public service is displayed.

      When the service recipient contacts the portal, documents are submitted in electronic copies.

      8. Terms of rendering a public service:

      from the moment of submission of the package of documents to the State Corporation, as well as when contacting the portal:

      when issuing a license and (or) annex to a license - 13 (thirteen) working days;

      upon reissuance of a license and (or) annex to the license - 3 (three) working days;

      when issuing a duplicate of the license and (or) annex to the license in case of loss or damage, issued in paper form - 2 (two) working days.

      When applying to the State Corporation, the day of receipt of documents is not included in the period for provision of the public service, while the result of provision of the public service by the service provider is provided to the State Corporation the day before the end of the term for provision of the public service.

      9. In accordance with subparagraph 11) of paragraph 2 of Article 5 of the Law, entering data into the information system for monitoring the provision of public services are established by the Rules for entering data into the information system for monitoring the provision of public services on the stage of provision of public service, approved by order of the acting Minister of Transport and Communications of the Republic of Kazakhstan dated June 14, 2013 No. 452 (registered in the Register of state registration of regulatory legal acts under No. 8555).

      10. Appealing decisions, actions (inaction) of the service provider on the issues of provision of public services is carried out by filing a complaint addressed to the head of the service provider, the authorized bodies in the field of health care or on the issues of provision of public services.

      Terms of consideration of complaints from the date of registration:

      1) by the service provider - within 5 (five) working days.

      2) by authorized bodies in the field of health care or on the issues of provision of public services - within 15 (fifteen) working days.

      In case of disagreement with the results of provision of public service, the service recipient applies to the court in accordance with the procedure established by the legislation of the Republic of Kazakhstan.

  Appendix 1
to the Rules for provision of public
service "Issuance of license for
medical activity"

Public service standard "Issuance of a license for medical activity"

1

Service provider name

Local executive bodies of regions, cities of republican significance and the capital

2

Methods of provision of a public service

1) non-profit joint stock company "State Corporation "Government for Citizens" (the State Corporation);
2) web portal of "electronic government" www.egov.kz, www. elicense.kz (hereinafter referred to as the portal)

3

Term of provision of a public service

13 (thirteen) working days

4

Form of provision

Electronic (partially automated) and (or) paper

5

Result of provision of a public service

license and (or) annex to the license, reissuance of the license and (or) annex to the license, duplicate of the license and (or) annex to the license for medical activity, or a reasoned refusal to provide a public services

6

Payment amount

The public service is provided for fee, the following license fee is charged:
1) for issuing a license - 10 monthly calculation indices (hereinafter - MCI);
2) for re-issuing a license - 10% of the rate when issuing a license, but not more than 4 MCI;
3) for issuing a duplicate license - 100% of the rate for issuing a license.

7

Schedule

1) the service provider - from Monday to Friday from 9.00 to 18.30 with a lunch break from 13.00 to 14.30, except for weekends and holidays;
2) the State Corporation - from Monday to Saturday, in accordance with the established work schedule from 9-00 to 20-00, without a lunch break, except for Sundays and holidays;
3) portal - around the clock, with the exception of technical breaks related to repair works (when the service recipient applies after the end of working hours, on weekends and holidays, applications are accepted and the results of provision of a public service are issued on the next working day).

8

List of documents

1) to obtain a license and an annex to a license:
an application (for individuals in accordance with Appendix 3, for legal entities in accordance with Appendix 4 to these Rules);
identity document - for an individual (required for personal identification);
a document confirming the payment of the license fee to the budget for the right to engage in certain types of activities, with the exception of payment through the payment gateway of "electronic government" (hereinafter referred to as PGEG);
the form of information confirming the availability of information and documents in accordance with the qualification requirements for licensing medical activity, in accordance with Appendix 5 to these Rules;
a document certifying the right of ownership, lease or trust management of state property to a premise or building, concluded for a period of less than one year (notarized if the original was not submitted for verification);
diploma of higher or secondary medical education (notarized in case of failure to submit the original);
certificates of completion of retraining or certificates of completion of advanced training (notarized in case of failure to submit the original);
a copy of the certificate of a specialist in the declared specialty;
a document confirming the labor activity of the employee, according to the declared subtypes of activity in accordance with Article 35 of the Labor Code of the Republic of Kazakhstan (notarized in case of failure to submit the original);
2) upon reissuance of a license and (or) annex to a license:
an application (for individuals in accordance with Appendix 6, for legal entities in accordance with Appendix 7 to these Rules);
a document confirming the payment of the license fee for the right to engage in certain types of activities, with the exception of payment through PGEG, for cases of license reissuance;
copies of documents containing information on changes that served as the basis for reissuing the license and (or) annex to the license, with the exception of documents, information from which is contained in state information systems;
Upon receipt of a reissued license, the service recipient returns to the service provider a previously issued paper license and (or) annex to the license.
3) to obtain a duplicate of the license and (or) annex to the license:
an application (for individuals in accordance with Appendix 8, for legal entities in accordance with Appendix 9 to these Rules);
a document confirming the payment of the license fee to the budget for the right to engage in certain types of activities, with the exception of payment through PGEG.
When the service recipient contacts the portal, documents are submitted in electronic copies.

9

Grounds for refusal to provide a public service established by the legislation of the Republic of Kazakhstan

1) establishing the inaccuracy of the submitted documents and (or) data (information) contained therein;
2) non-compliance of the service recipient and (or) the submitted materials, objects, data and information necessary for provision of a public service with the requirements established by the regulatory legal acts of the Republic of Kazakhstan;
3) in relation to the service recipient there is a court decision that has entered into legal force, on the basis of which he is deprived of a special right related to the receipt of a public service.

10

Other requirements, taking into account the specifics of provision of a public service, including those provided in electronic form

1. The service recipient has the opportunity to receive information about the procedure and status of the provision of a public service in remote access mode through the "personal account" of the portal, as well as a unified contact center.
2. Contact numbers of reference services on provision of a public service are indicated on the Internet resource of the authorized body in the field of healthcare www.gov.egov.kz.
The telephone numbers of the unified contact center for provision of public services are 1414, 8 800 080 7777.

  Appendix 2
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

______________________________________________________________
(surname, name, patronymic (if any) or the name of the service recipient's Organization)
      ____________________________________________________________________
(service recipient's address)
Receipt of refusal to accept documents

      Guided by subparagraph 2 of article 20 of the Law of the Republic of Kazakhstan dated April 15, 2013 "On

      public services", department No. ____ of the branch of the State Corporation (specify the address) refuses to accept documents for provision of a public service (indicate the name of the public service in

      accordance with the Rules) due to the submission by you of an incomplete package of documents according to the list, provided by the list, namely:

      Name of missing documents:

      1) ________________________________________;

      2) ________________________________________;

      3) ________________________________________.

      This receipt is written in 2 copies, one for each party.

      surname, name, patronymic (if any) (of an employee of the State Corporation)

      _________________________________________________________

      (signature)__________________________________

      Executive surname, name, patronymic (if any) ______________________

      Tel .: _______________________________________

      Received: _______________________________________________________

      surname, name, patronymic (if any) / signature of the service recipient /

      "_____" ____________ 20____

  Appendix 3
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of an individual for obtaining a license and (or) annex to a license

      To________________________________________________________________

      (full name of the licensor)

      from________________________________________________________________

      (surname, name, patronymic (if any) of an individual, individual identification number)

      I ask to issue a license and (or) an annex to a license for implementation _______________________________________________________________

      (indicate the full name of the type of activity and (or) subtype (s) of the activity)

      on paper ___________________________________________________

      (put an X sign if it is necessary to obtain a license on paper)

      Residence address of an individual

      _______________________________________________________________________

      (postal code, region, city, district, locality, street name,

      house / building No. (stationary premises)

      Email __________________________________________________________

      Phones _________________________________________________________

      Fax ____________________________________________________________

      Bank account ____________________________________________________

      (account number, name and location of the bank)

      Address of the object of implementation of the activity or actions (operations)

      ________________________________________________________________________

      (postal code, region, city, district, locality, street name,

      house / building No. (stationary premises)

            _____ sheets attached.

      It is hereby confirmed that:

      1) all specified data are official contacts and any information may be sent to

      them on the issues of issuance or refusal to issue a license and (or)

      annexes to the license;

      2) the applicant is not prohibited by the court from engaging in the licensed type and

      (or) a subtype of activity;

      3) all attached documents are true and valid;

      4) the applicant agrees to the use of personal data of limited access,

      constituting a secret protected by law, contained in information systems, when

      issuing a license and (or) annex to the license;

      5) the applicant agrees to certify the application with an electronic digital signature of

      an employee of the State Corporation (in case of applying through the State Corporation).

      Individual _____________ ___________________________________

      (signature) (full name (if any)

      Stamp here (if available)

      Date of filling: "_____" ___________ 20_____

  Appendix 4
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of a legal entity for obtaining a license and (or) annex to a license

      To_____________________________________________________________

      (full name of the licensor)

      from____________________________________________________________

      (full name, location, business identification number of a legal entity (including a foreign legal entity), business identification number of a branch or representative office of a foreign legal entity - if the legal entity does not have a business identification number)

      I ask to issue a license and (or) an annex to a license for implementation

      ____________________________________________________________________

      ____________________________________________________________________

      (indicate the full name of the type of activity and (or) subtype (s) of activity) on paper _____ (put an X sign if it is necessary to get a license on paper)

      Legal entity address ________________________________________

      ____________________________________________________________________

      (postal code, country (for a foreign legal entity), region, city, district,

      locality, street name, house / building number (stationary premises)

      Email _________________________________________________________

      Phones ________________________________________________________

      Fax ___________________________________________________________

      Bank account____________________________________________________

      (account number, name and location of the bank)

      Address of the object of implementation of the activity or actions (operations)

      ____________________________________________________________________

      ____________________________________________________________________

      (postal code, region, city, district, locality, street name, house / building No (stationary premises).

      ______ sheets attached.

      It is hereby confirmed that:

      1) all specified data are official contacts and any information may be sent to them

      on the issues of issuance or refusal to issue a license and (or) annexes to the license;

      2) the applicant is not prohibited by the court from engaging in the licensed types and

      (or) a subtype of activity;

      3) all attached documents are true and valid;

      4) the applicant agrees to the use of personal data of

      limited access, constituting a secret protected by law,

      contained in information systems when issuing a license and (or)

      annexes to the license;

      5) the applicant agrees to certify the application with an electronic digital

      signature of an employee of the State Corporation (in case of contact through the

      State Corporation).

      Head _____________ _____________________________________

      (signature) (full name (if any)

      Stamp here

      Date of filling: "_____" _________ 20____.

  Appendix 5
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Information form confirming the availability of information and documents in accordance with the qualification requirements for licensing medical activity.

      Information confirming availability of:

      1. Premises or buildings on the basis of ownership or a lease agreement and a floor plan of the specified

      premises (buildings):

      Information about registration of the real estate object

      1) Cadastral number ________________

      2) Location___________________

      3) Number of the certificate of state registration of real estate ___________________________

      4) Rental agreement number __________________

      5) Date of the lease contract __________________

      2. Medical and (or) special equipment, apparatus and instruments, devices,

      furniture, inventory, vehicles and other means, according to the declared subtypes of medical activity:

Name of medical and (or) special equipment, apparatus and instruments, devices, furniture, inventory, transport and other means (according to the passport)

The country of manufacture

Unit of measurement

Quantity

Year of issue

Condition (working / not working)








      3. Corresponding education according to the declared subtypes of medical activity:

      Information about medical education

      1) Diploma specialty ___________________________________

      2) Qualification by diploma ______________________________

      3) Diploma number ____________________________________

      4) Series of diploma ____________________________________

      5) Full name of the educational organization ________________

      6) Year of enrollment __________________________

      7) Year of graduation ___________________________

      8) Information on nostrification of the diploma (if necessary) __________

      4. Specializations or improvements and other types of advanced training for the last

      5 years for the declared subtypes of medical activity:

      Information about advanced training in the declared specialty

      1) Document number __________________________________

      2) Cycle name ________________________________________

      3) Full name of the training organization ___________________

      4) Start of training _____________________________________

      5) Completion of training ___________________________

      6) Number of hours ________________________________

      5. Appropriate specialist certificate:

      Specialist Certificate Information

      1) The name of the specialty for which the specialist certificate was issued

      2) Qualification category (if any, specify)

      3) Authority that issued the specialist certificate

      4) Registration number

      5) Date of issue _______________________________________________

      6) Certificate validity period______________________________________

      6. Staff of medical workers, which is confirmed by information about medical workers:

      Information about medical workers of medical organizations (for a legal entity)

      ________________________________________________

      (name of the health care subject)

      (as of "____" __________ 20___).


Surname

Name

Patronymic

Position held

Education

Professional experience

Number, series of diploma Specialty and qualification according to the diploma

Full name of the educational organization
Year of enrollment
Year of graduation

Certificate of nostrification of the diploma (if necessary)











      7. For individuals - work experience in the specialty of at least 5 years for the declared subtypes of medical activity:

      Labor activity in the declared specialty (for an individual)

      1) Name of the medical organization ________________________

      2) Location of the organization ________________________________

      3) Position held _______________________________________

      4) Date of employment in the declared specialty ______________

      5) Date of dismissal ____________________________________________

  Appendix 6
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of an individual for re-issuing a license and (or) annex to a license

      To _____________________________________________________________

                              (full name of the licensor)

      from _____________________________________________________________

      (surname, name, patronymic (if any) of an individual, individual identification number)

            I ask to reissue the license and (or) annex to the license (underline the necessary)

      No. ____________ dated _________ 20___, issued __________

      (number (s) of the license and (or) annex (s) to the license, date of issue, name of the licensor who issued the license and (or) annex (s) to the license) to carry out ____________________________________________________________________

      (full name of the type of activity and (or) subtype (s) of activity) for the following reason (s) (indicate in the appropriate X cell):

      1) change of surname, name, patronymic (if any) of an individual - licensee __________________________________________________________

      2) re-registration of the individual entrepreneur-licensee, change of his name _______________________________________________________

      3) re-registration of an individual entrepreneur-licensee, change of his legal address ____________________________________

      4) alienation by the licensee of the license issued under the class "permits issued for

      objects", together with the object in favor of third parties in cases where the alienation of the license is provided for by Appendix 1 to the Law of the Republic of Kazakhstan "On permits and notifications" dated May 16, 2014 ______________________________________

      5) change of the address of the location of the object without its physical movement for

      a license issued under the class "permits issued for objects" or for annexes to a license indicating the objects ____________________________________________________

      6) the presence of a requirement for re-registration in the laws of the Republic of Kazakhstan

      _____________________________________________________________

      7) change of the name of the type of activity _______________________

      8) change of the name of the subtype of activity ____________________

      on paper _______ (put an X sign if it is necessary to obtain a license on paper)

      Residence address of an individual ___________________________

      ____________________________________________________________________

      (postal code, region, city, district, locality, street name, house / building No. (stationary premises).

      Email ________________________________________________

      Phones ________________________________________________________

      Fax ____________________________________________________________

      Bank account __________________________________________________

      Address of the object of implementation of the activity or actions (operations)

      _____________________________________________________________________

      _____________________________________________________________________

      (postal code, region, city, district, locality, street name,

      house / building No. (stationary premises).

      _____ sheets attached.

      It is hereby confirmed that:

      1) all specified data are official contacts and any information may be sent to them

      on the issues of issuance or refusal to issue a license and (or) annexes to the license;

      2) the applicant is not prohibited by the court from engaging in the licensed types and (or) subtypes of

      activities;

      3) all attached documents are true and valid;

      4) the applicant agrees to the use of personal data of limited access,

      constituting a secret protected by law, contained in information systems, when

      issuing a license and (or) annex to the license;

      5) the applicant agrees to certify the application with an electronic digital signature of

      an employee of the State Corporation (in case of applying through the State Corporation).

      Individual _________ _______________________________________

      (signature) (surname, name, patronymic (if any)

      Stamp here

      Date of filling: "____" _________ 20____

  Appendix 7
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of a legal entity for re-issuing a license and (or) annex to a license

      To _____________________________________________________________

                              (full name of the licensor)

      from _____________________________________________________________

      (full name, location, business identification number of a legal entity (including a foreign legal entity), business identification number of a branch or representative office of a foreign legal entity - if the legal entity does not have a business identification number)

      I ask to reissue the license and (or) annex (s) to the license (underline the necessary)

      No. __________ dated "___" _________ 20 ___, issued _________

      ____________________________________________________________________

      (number (s) of the license and (or) annex (s) to the license, date of issue, name of the licensor who issued the license and (or) annex (s) to the license)

      For implementation of _______________________________________________

      (full name of the type of activity and (or) subtype (s) of activity) for the following reason (s) (indicate in the appropriate X cell):

      1) reorganization of the legal entity-licensee in accordance with Article 34 of the Law of the Republic of Kazakhstan "On permits and notifications" dated May 14, 2014 (hereinafter - the Law) by (indicate in the appropriate X cell):

      merger ________________________________________________________

      reorganization _________________________________________________

      joining __________________________________________________

      division ______________________________________________________

      separation ____________________________________________________

      2) change of the name of the legal entity-licensee

      _______________________________________________________________________

      3) change of location of the legal entity-licensee

      ______________________________________________________________________

      4) alienation by the licensee of the license issued under the class "permits issued for

      objects", together with the object in favor of third parties in cases where the alienability of the license is

      provided by Appendix 1 to the Law

      _______________________________________________________________________

      ______________________________________________________________________

      5) change of the address of the location of the object without its physical movement for

      licenses issued under the class "permits issued for objects" or for annexes to

      licenses indicating objects _____________________________________________________

      __________________________________________________________________________

      6) the presence of a requirement for re-registration in the laws of the Republic of Kazakhstan

      __________________________________________________________________________

      7) change of the name of the type of activity _______________________

      8) change the name of the subtype of activity ________________________

      on paper _____ (put an X sign if it is necessary to obtain a license on paper).

      Legal entity address _______________________________________

      (country - for a foreign legal entity, postal code, region, city, district,

      locality, street name, house / building No. (stationary premises).

      Email_______________________________________________

      Phones ______________________________________________________

      Fax __________________________________________________________

      Bank account ________________________________________________

      (account number, name and location of the bank)

      Address of the object of the activity or actions (operations) ___________________________________________________________

      (postal code, region, city, district, locality, street name,

      house / building No. (stationary premises).

      ______ sheets attached.

      It is hereby confirmed that:

      1) all specified data are official contacts and

      any information may be sent to them on the issues of issuance or refusal to

      issue a license and (or) annex to the license;

      2) the applicant is not prohibited by the court from engaging in the licensed types and (or) subtypes of

      activities;

      3) all attached documents are true and valid;

      4) the applicant agrees to the use of personal data of

      limited access, constituting a secret protected by law,

      contained in information systems when issuing a license and (or)

      annexes to the license;

      5) the applicant agrees to certify the application with an electronic digital

      signature of an employee of the State Corporation (in case of contact through the

      State Corporation).

      Head _____________ _____________________________________

      (signature) (surname, name, patronymic (if any)

      Stamp here

      Date of filling: "_____" __________ 20____

  Appendix 8
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of an individual for obtaining a duplicate license and (or) annex to the license

      To ____________________________________________________________

                              (full name of the licensor)

      from __________________________________________________________________

      (surname, name, patronymic (if any) of an individual, individual identification number)

            I ask to issue a duplicate of the license and (or) annex to the license for

      implementation _______________________________________________________

      (indicate the type of activity and (or) subtype (s) of the activity)

      Residence address of an individual _______________________________________

      ____________________________________________________________________

      (postal code, region, city, district, locality, street name, house / building No.)

      Email _______________________________________________________

      Phones ______________________________________________________

      Fax __________________________________________________________

      Bank account _________________________________________________

      (account number, name and location of the bank)

      Address (s) of the activity ______________________________

      (postal code, region, city, district, locality, street name, house / building No. (stationary premises)

      _____ sheets attached.

      It is hereby confirmed that:

      all specified data are official contacts and any information may be sent to

      them on the issues of issuance or refusal to issue a license and (or)

      annexes to the license;

      the applicant is not prohibited by the court from engaging in a licensed type and (or) subtype of activities;

      all attached documents are true and valid.

      I agree to the use of information constituting a secret protected by law,

      contained in information systems.

      Individual ____________ ___________________________________

      (signature) (surname, name, patronymic, if any)

      Stamp here (if available)

      Date of filling: "_____" __________ 20_____.

  Appendix 9
to the Rules for provision of public
service "Issuance of license for
medical activity"
  Form

Application of a legal entity for obtaining a duplicate of a license and (or) annex to the license

      To _____________________________________________________________

                              (full name of the licensor)

      from _____________________________________________________________

                  (full name of the legal entity, BIN)

      I ask to issue a duplicate of the license and (or) annex to the license for

      implementation _______________________________________________________

      (indicate the type of activity and (or) subtype (s) of the activity)

      Legal entity address ________________________________________

      (postal code, region, city, district, locality, street name, house / building No. (stationary premises)

      Email ______________________________________________

      Phones ______________________________________________________

      Fax __________________________________________________________

      Bank account _________________________________________________

      (account number, name and location of the bank)

      Address (s) of the activity ______________________________

      (postal code, region, city, district, locality, street name, house / building No. (stationary premises)

      ______ sheets attached.

      It is hereby confirmed that:

      all specified data are official contacts and any information may be sent to them

      on the issues of issuance or refusal to issue a license and (or) annexes to the license;

      the applicant is not prohibited by the court from engaging in a licensed type and (or) subtype of

      activities;

      all attached documents are true and valid.

      I agree to the use of information constituting a secret protected by law,

      contained in information systems.

      Service recipient _______________________________________________

      (signature) (last name, first name, patronymic (if available)

      Stamp here (if available)

      Date of filling: "____" _________ 20____

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