Part 2, Chapter 4: Manual Appendix A

I, ______________________________________
                              (Name)

Address:________________________________________________________________________________________

Name & Address of Employer ________________________________________________________________________

Employee Identification* _____________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

hereby apply for medical care for:

____ Myself and/or ____ My dependents as follows:

(Use reverse side if additional space is needed.)

I understand that I will be charged for the care furnished, at the current Bureau of the Budget rates, and that a false or fraudulent statement is punishable under 18 U.S.C.§100].

_____________________________________________
(Signed)                         ;    

*  Show credentials, government drivers license, building pass, employees' assn. or credit union membership card, and/or Social Security No., or certification by employing unit or official.