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  • Cghs Application Form

    Enviado por

    Sushant Saxena
    255 visualizações4 páginas
    cghs

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    cghs

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    255 visualizações4 páginas

    Cghs Application Form

    Enviado por

    Sushant Saxena
    cghs

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 4

    APPLICATIONFORNEWCGHSCARDPrintback

    AcknowledgementNo.T700635

    1.NameoftheApplicant:MANJARIKUMARI/

    2.Category

    Departmental

    Services YES

    Pensioners

    Others(Pl.Specify)......

    {PleaseTickDepartmentalifyouarepostedintheMinistryofHealth&FamilyWelfare/DGHS/CGHS}
    {PleaseTickServicesifyoubelongtoanyspecificorganizedservice}
    3.NameofDepartment/Service:ChiefCommissionerCentralExcise
    4.Designation..............................

    Gazetted YES

    NonGazetted

    5.ScaleofPay:PB29300348004600PresentPay:18190rs.
    6.LastPay/BasicPension(incaseofPensioners):.........
    7.OfficialAddress:OFFICEOFCOMMISSIONEROFCENTRALEXCISE,ANNEXBUILDING,26/1MGROAD,NUNGAMBAKKAM,CHENNAI,
    TAMILNADU,CHENNAIPin:600034...................................
    ........................................
    8.ResidentialAddress:HOUSENO.3,NARAYANAAPARTMENT,,VARADARAJAPETMAINROAD,CHENNAIPin:
    600024.............................
    ..................................................9.TelephoneNumber:(O)7358626758(R)(M)
    917358626758
    10.EmailId:manjari2604@gmail.com
    11.DateofSuperannuation:__/__/____DateMonthYear
    12.AreyouonDeputation(CentralDeputation)Yes/No
    13.Ifyes,likelycompletionofDeputation
    14.Areyourservicestransferabletoothercities:Yes/No
    15.DetailsofFamily
    (*PleaseseedefinitionofFamilybeforefillingupthiscolumn)

    S.No.
    1.

    NameofFamily
    member
    MANJARIKUMARI

    RelationshiptoCGHSCard
    Holder
    SELF

    DateofBirth BloodGroup(optional)

    MobileNo

    26041988

    7358626758

    {#PleaseattachProofofageofPersonsmentionedabove}(P.T.O.)
    6.Areallthepersonswhosenamesaregivenabovearedependantuponyouandareresidingwithyou?Yes/No
    {Pleaseattachproofoftheirstayingwithyou,likecopyofRationCard/ElectionID/PassPort/IdentityCardissuedbyCollege/
    School/University/BankPassBook,etc.,}
    17.PasteoneIDCardsizeofPhotographofeachmemberofFamily(includingself)whosenamesareproposedtobeincludedas
    partofyourfamilyinthespacegivenbelow.

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    S.No...................

    IUndertaketointimatetoCGHSimmediatelyifthereisanychangeindependencycriteriaofmyfamilymembersincludedinthis
    applicationform.IfIfailtointimateandiftheCGHScomestoknowofthechangethentheCGHSfacilityisliabletobewithdrawnby
    theCGHSandtheCGHSand/orappropriateauthoritywillbefreetoinitiateanyactionagainstme.
    IUndertaketosurrendertheCGHSCard(s)onmyleavingtheMinistry/Officeontransferretirementtermination.Resignation
    oronceasingtobeeligibleforCGHSbenefits.
    Icertifythattheinformationfurnishedbymeinthisapplicationhasbeenverifiedtobecorrectandthatnoinformationhasbeen

    concealedorhasbeenmisrepresentedandIstandbythesame.

    Encl.ProofofResidence/Stayofdependents
    Proofofageofson/Disabilitycertificate
    SurrenderCertificateofCGHSCardwhileinservice
    AttestedcopiesofPPO&LasrPayCertificateSignatureofApplicant.

    (TOBEFILLEDBYTHESPONSORINGAUTHORITY)
    Theinformationfurnishedbytheapplicanthasbeenverifiedandfoundtobecorrect.ItisrecommendthataCGHS
    CardbeissuedtoShri/Smt./Kumari.........................,Designation...........................InthisMinistry/Department/Organization.
    InstructionsareissuedtotheconcernedDivisiontostartdeductingCGHSSubscriptionseverymonthfromthesalaryoftheapplicant
    /CGHSSubscriptionsaredeductedeverymonthfromthesalaryoftheapplicant.Iamauthorizedsponsoringauthorityfortheissue
    ofCGHSCardandapprovaloftheCompetentauthorityhasbeenobtained.
    No.
    DateSignature&Nameof
    theSponsoringAuthority
    Designation(Stamp)withTel.Number
    VerifiedbyAuthorizedSignatory,CGHS(HQ)
    SignaturewithStamp(forCGHSpensionersmakingcardFirstTime)
    To
    ChiefMedicalOfficeri/c,CGHSDispensaryNo.

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