Form 1—Application for approval as an orForm 1—Application for approval as an organization under Part IV

Form 1—Application for approval as an organization under Part IV

(regulation 21)

HEALTH INSURANCE ACT

APPLICATION FOR APPROVAL AS AN ORGANIZATION UNDER PART IV

To: the Minister of State for Health.

(Name of applicant organization)

of ,

(Address of applicant organization)

hereby makes application under subsection 40(1) of the Health Insurance Act 1973 for approval as an organization under Part IV of that Act.

Dated this day of , 19

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(Signature of person authorized to

sign application)

.............................

(Position in organization)