Form -A Application For Cghs Card For Serving Employees Of Central Government

ADVERTISEMENT

FORM –A
APPLICATION FOR CGHS CARD FOR SERVING EMPLOYEES OF CENTRAL GOVERNMENT
1. Name of the Applicant: …………………………………………………………………………………………………
2. Category --
Departmental
Services
{ Please Tick Departmental if you are posted in the Ministry of Health & Family Welfare/ DGHS / CGHS }
{ Please Tick Services if you belong to any specific organized service }
3. Name of Department ………………………………………………………………………………………………………………
4. Name of the Service……………………………………………………………………………………………………………….
( in case of All India / Central Services – IAS/IPS. Etc., )
5. Designation …………………………………………
Gazetted
Non-Gazetted
5. Pay Band ………………………………………….. Present Pay ………………………………Grade Pay…………………..
( for Serving Employees)
7. Official Address :…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
8. Residential Address:…………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
9. Telephone Number: ( O )
( R )
( M )
10. e-mail ID
11. Date of Superannuation:
_ _ / _ _ / _ _ _ _
Date Month
Year
12. Are you on Deputation (Central Deputation)
Yes / No
13. If yes, likely date completion of Deputation
……………………………………………..
14. Are your services transferable to other cities:
Yes / No
15. Details of Family
{* Please see definition of Family before filling up this column}
S.No.
Name of Family member
Name in Hindi
Relation ship to
Date of Birth#
Blood Group
CGHS Card Holder*
(Compulsory)
(optional)
Self
{# Please attach Proof of age of Persons mentioned above}
16. Are all the persons whose names are given above are dependant upon you and are residing with you?
Yes / No
{Please attach proof of their staying with you , like copy of Ration Card / Election ID / Pass Port / Identity Card issued by
College / School / University / Bank Pass Book , etc., }

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2