REVISED MRS OPTION FORM OF MADURAI SSA

HRMS NO                                                                                          CONTACT NO:

BHARAT  SANCHAR NIGAM LIMITED

(A GOVERNMENT OF INDIA ENTERPRISE)

BSNL MRS REGISTRATION FORM FOR RETIRED EMPLOYEES.

1.NAME OF THE RETIRED EMPLOYEE:                                    2.FATHER’S NAME:

3.PLACE OF LAST POSTING:                                                     4.DESIGNATION:

5.LAST SALARY DRAWM(i)Basic pay:                                        (ii) DA:

6.ADDRESS AFTER RETIREMENT:

7. TELEPHONE No                                                      8.EMAIL ID

9. NEAREST BSNL SSA OFFICE

10.DETAILS OF FAMILY MEMBERS

SL NO	NAME	DOB	RELATION SHIP WITH RETIRED EMPLOYEE

11.  OPTION FOR OUTDOOR TREATMENT(UNDER BSNL MRS)  (TICK either (i) or (ii))

i)  Outdoor/Domiciliary treatment from RMPs/Reimbursement                            🔄

    Against Vouchers (as per para 2.1.0)                                                   

ii) Outdoor/Domiciliary treatment Entitlement without Vouchers                        ⬋

   (as per para2.1.1)

12. PAN NO:                                                                         13.AADHAR NO:

14.Bank Details A/C NO:                                                       IFSC CODE:

Declaration

       I hereby declare that the above mentioned members of my family   are fully dependant on me and their income from all sources does not exceed Rs.9000/-per month. If the above information is found to be false at any time, company can take action against me as per Rules or as deemed fit.

                                                                                            Signature of the retired Employee

ENCLOSURES

Copy of  PPO /revised PPO if any

Copy ofMRS Card

Checked     DA                                  JAO(PC)                                             AO (TA)