LICATI POINT! ‘TENSIO} EW. AUTHORISI MED! ‘TTENDANTS (AMA) 1. Name of Employee Shri/Smt./Km, 2, Designation 3, Seale of pay 4. Branch and Telephone No. 5. Date of Surrender of CGHS Card 6. Residential Address of the employee (If not having Govt. accommodation) 7. Details of Family Members in respect of whom treatment is intended to be taken from the aforesaid AMA SL | Name of Family Members Date of Birth | Relation to the employee No. OL 02 03 04 05 06 07 08 8. Name of the doctor proposed to be appointed as AMA 9. Residential address of the Doctor 10. Address of the Clinie of the doctor 11, Approximate distance between the residence of the employee and the clinic of the doctor : Contd...2/-12, Whether the Proposed doctor has been appointed as AMA by any Ministry / Department of Government of India. If so furnish details and enclose a photocopy of the appointment letter. A = 13. Whether the consent of the doctor has been taken , if so please enclose the same. 14. request that the above proposed doctor may kindly be considered for appointment as Authorised Medic members whose details are given above (Para-7) Attendant (AMA) for medical treatment of myself and my family members mentioned above in respect of whom 1 15, I declare that the all my fami intend to take medical treatment from the proposed AMA are actually dependent on me. I assure that I will bring it to the notice of AN-I Branch immediately after any of my family member ceases to be dependent on me, for deletion for his / her name from the entitled category. 16. I hereby further declare that all the information / details furnished above are true and factually correct. If at any stage any information is found to be incorrect, I shall be liable to appropriate administrative action besides cancellation of my application Signature: Name ‘ ate :FOR OFFICIAL USE ONLY (for Gazetted Official) (A) The details furnished by Shri/Smt/Km, in column No. 7 regarding family details have been verified from the records and found to be correct. The family members as mentioned by the applicant in column No. 7 are actually dependant on him, (EXECUTIVE OFFICER) PA(MG) Branch Date: (B) The details furnished by Shri/Smt/Km, in column No, 5 regarding CGHS Card have been verified from the records and found to be correct. It column No. also certified that the area of residence of the applicant as mentioned in not covered under CGHS. (EXECUTIVE OFFICER) AN-II Branch Date: (for Non-Gazetted Official) (A) The details furnished by Shri/Smt/Km. details have been verified from the records and found to in column No. 7 regarding fa be correct. The family members as mentioned by the applicant in column No. 7 are actually dependant on him, (B) The details furnished by Shri/Smt/Km, in column No. 5 regarding CGHS Card have been v jed from the records and found to be correct. It is also certified that the area of residence of the applicant as mentioned in column No, 6 is not covered under CGHS. (EXECUTIVE OFFICER) AN-IE Branch Date: