Appendix :1/51
Concession for Thalsamia Major
Patients :
Concession Certificate Rule No.101 S.No. 31(1) &31(2)

Form for the purpose of issue of Rail Concession to Thalsamia Major patients to be used by the officer-in-charge of the Hospital recognized by Health Departments of the Central Governments on the concerned State Government

The Station Master,___________
_______________________________
____________________________________
This is to certify that Shri/Smt_______________________________ whose particulars are furnished below is a bonafide Thalsamia Major patient and is required to travel from______________________________(station) to _________________________(station) for discharge from/after re-examination/periodical Check up at_______________ Hospital.He is entitled to a single journey ticket on payment of ¼ th the Normal Fare due for the patient and attendant.
Particulars of the Thalsamia Major Patient.
(a) Age___________ (b) Sex____________
(c) Personal Identification Marks : 1)______________________
2)______________________
(d) Signature or Left Hand Thumb
Impression of the patient :
Place: ____________________ Signature:
Date:_____________ Officer-in-charge of the Hospital recognized by health department of Central government/state government of____________________
(Name of the state).
Seal of the recognized Hospital:
Strike out where not applicable
Indicate name of the Hospital recognized by Health Department of Central Government or state Government Concerned.
Note: 1) The certificate is valid for one year from the date of issue.
2) No alteration in the form is permitted.
3) Certificate should be issued to patients only for travelling from the station serving the recognized hospital to the station serving his place of residence.