Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) Page 2
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172
Application Regn No
PART-II PARTICULARS OF DEPENDANTS
Name of
SPOUSE
(Maximum 20 Characters including space)
Gender
(
)
Citizenship (
)
Indian
NDG
Male
Female
Affix Recent Colour
Passport size Photo
Date of Birth
(DD-MM-YYYY)
of SPOUSE of
Pensioner
Date of Marriage
(DD-MM-YYYY)
Parent Polyclinic
(If not same as pensioner/
Family pension)
Yes
No
Yes
No
Disability(
Physical
)
Code
Employed( )
Monthly Income ____________
Aadhar Card No __________________________ PAN No : _______________________
Yes
No
( )
Blood Group
Name Mentioned in Service/ Discharge Book
Drug Allergy (if any)
Residential
Address
(If not same as pensioner/
Family pension)
Tehsil
Dist
State
Pin
Contact details
Mob
(a)
Tele No
(With STD code)
(b)
E Mail ID :-
Name of
Dependent
(Maximum 20 Characters including Space)
FATHER
Citizenship (
)
Affix Recent Colour
Indian
NDG
Passport size Photo
of Dependent
Date of Birth
(DD-MM-YYYY)
FATHER of
Employed ( )
Pensioner (
)
Pensioner
Yes
No
Yes
No
No
Whether dependent on applicant (
)
Yes
Monthly income ___________
Parent Polyclinic
(If not same as pensioner/
Family pension)
Yes
No
Name Mentioned in Service/Discharge Book ( )
Physical Disability ( )
Code
No
Yes
Aadhar Card No __________________ PAN No : _______________
Blood Group
Drug Allergy (if any)
Residential
Address
(If not same as pensioner/
Tehsil
Dist
Family pension)
State
Pin
Contact details
Mob
(a)
Tele No
(With STD code)
(b)
E Mail ID :-
Name of
Dependent
(Maximum 20 Characters including Space)
MOTHER
Indian
Citizenship (
)
NDG
Affix Recent Colour
Date of Birth
(DD-MM-YYYY)
Passport size Photo
Dependent
of
Yes
No
Employed ( )
Pensioner (
)
Yes
MOTHER of
No
Pensioner
No
Whether dependent on applicant
(
)
Yes
Monthly income _________
Parent Polyclinic
(If not same as pensioner/
Family pension)
No
Yes
Yes
No
( )
Code
Name Mentioned in service/Discharge Book ( )
Physical Disability
Aadhar Card No____________________ PAN No :____________________
Blood Group
Drug Allergy (if any)
Residential
Address
(If not same as pensioner/
Tehsil
Dist
Family pension)
State
Pin
Contact details
(a)
Tele No
Mob
(With STD code)
(b)
E Mail ID :-
Note :-
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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