Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015)

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EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)
APPLICATION FORM FOR MEMBERSHIP (REV 2015)
(PLEASE FILL IN CAPITALS & IN BLUE INK)
Applicant’s
Recent Colour
Application Regn No.
Passport size
Photograph in
Place of Submission
Civil Dress
Category
( )
(a)
Officer (b)
JCO & Equivalent
(c)
OR & Equivalent
PART I - PARTICULARS OF PENSIONER
APPLICATION FOR (
)
Family Pensioner
Pensioner
Future Retiree
SERVICE ( )
Army
Navy
CG
DSC
SFF
Air Force
Signature of Applicant
1.
Service No
2. Rank
(With prefix and suffix)
(Abbreviated as per General Instructions)
3.
(a)
Name of Ex-Serviceman
(Maximum 32 characters
including spaces)
(i)
Regt/Corps/Ship/Base/Unit : _________________
(ii) Gender
(
)
Male
Female
Indian
NDG
Others
(iii) Citizenship ( )
(iv) Marital Status (
)Married/Unmarried/Divorce/Widow/Widower
Yes
No
(v)
Employed
( )
(vi) Monthly Income: __________________________
(b) Name of family Pensioner
(if applicable)
(ii) Category ( ) Officer/JCO & Equivalent/OR & Equivalent
(i) Gender (
)
Male
Female
Indian
NDG
(iii) Employed (
)
(iv) Citizenship (
)
(v) Monthly income ____________
Yes
No
(c)
Relationship with ESM ( ) Spouse/ Dependent Son/ Dependent Daughter/ Dependent Father/ Dependent
Mother/ Dependent Brother / Dependent Sister
(d) Date of Demise of Pensioner
(DD-MM-YYYY)
(e)
Aadhar Card No __________________________________
(f)
PAN No : __________________________________
4.
Date of Birth of Applicant
(DD-MM-YYYY)
Primary Member
5.
Date of Commission/ Enrollment
(DD-MM-YYYY)
6.
Date of Retirement/ Discharge
(DD-MM-YYYY)
7.
Parent Polyclinic
8.
Residential
Address
Tehsil
Dist
State
Pin
9.
Contact details
(a)
Telephone No
(With STD code)
(b)
Mob No
(c)
E-Mail ID :-
Normal
Disability
Family
10.
Type of Pension ( )
11.
Pension Payment Order No (PPO No)
(attach photo copy)
12.
Name & Address of
Banker/Treasury from
where pension drawn
13.
Pension Bank
Account Number
14.
Record Office
15.
Drug Allergy (if any)
16.
Blood Group
Physical Disability ( )
Code
Yes
No
(Optional) (Tick one as applicable) War Disability/Battle Casualty Disability (
)
Yes
No
Signature and stamp of authorising Officer of Station Headquarters/ Record Office.
Note :-
Para 16 code for Physical disability
,,
01
Blindness
06
Mental Retardation
02
Low Vision
07
Mental Illness
03
Leprosy – Cured person
08.
Autism
04
Hearing Impairment
09.
Cerebral Palsy
05
Loco motor disability
10
Multiple Disabilities

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