Annexure - I . ‘Serving Employee BHARAT SANCHAR NIGAM LIMITED (GOVERNMENT OF INDIA’S ENTERPRISE) % The Principal General Manager, BSNL, D.T.O, Compound, Ahmednagar-414001, SPECIMAN FORMAT APPLICATION FOR ISSUE OF AUTHORISATION LETTER (Controlling Officer of the official) t im Is thorisation Letter for taking INDOOR TREATMENT in the Empanelled Hospit Under BSNL MRS to SER\ RETIRED BSNL Employees. 7 T the undersigned am working as/Retired as is to inform you that my self / wife / son / Daughter / mother / father / in law ‘Shri/Smt/Master/Miss Hospital in/from % BSNL, It is to be / was admitted in (Name of Hospital) on dated __/_/- Further I hereby declare the above mentioned patient is wholly dependent upon me and resides with me.His monthly income does not exceed Rs.9000/-(Rs. Nine thousand) You are therefore requested to issue authorisation letter to (Name of Hospital). Name | Male / Female | Relationship with | Date of Birth The Employee Thanking you. Yours Sincerely, DATE= / 20 : Signature of Employee Name & Desgn- Designation-. COUNTER SIGNATURE OF HOSPITAL AUTHORITY WITH SEAL ‘Section/Sub-Divn-. oMDTRE E assilectieslnc ine martin