Form -A Application For Cghs Card For Serving Employees Of Central Government (Page 2 of 2) in pdf

Form -A Application For Cghs Card For Serving Employees Of Central Government Page 2

17. Paste one ID Card size of Photograph of each member of Family (including self) whose names are proposed to be

included as part of your family in the space given below.

S.No ………..

S.No. ………

S.No……..

S.No……

Name

S.No ………..

S.No. ………

S.No……..

S.No……

Name

I Undertake to intimate to CGHS immediately if there is any change in dependency criteria of my family members

included in this application form. If I fail to intimate and if the CGHS comes to know of the change then the CGHS facility is

liable to be withdrawn by the CGHS and the CGHS and / or appropriate authority will be free to initiate any action against

me.

I Undertake to surrender the CGHS Card(s) on my leaving the Ministry / Office on transfer; retirement;

termination. Resignation; or on ceasing to be eligible for CGHS benefits.

I certify that the information furnished by me in this application has been verified to be correct and that no

information has been concealed or has been misrepresented and I stand by the same.

Encl. Proof of Residence / Stay of dependents

Proof of age of son/ Disability certificate

Signature of Applicant.

Form -A Application For Cghs Card For Serving Employees Of Central Government Page 2