Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) Page 4

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4
Name of
Dependent
(Maximum 20 Characters including space)
Brother
Citizenship (
)
Indian
NDG
Affix Recent
Date of Birth
(DD-MM-YYYY)
Colour Passport
size Photo of
Yes
No
Relationship
Employed ( )
(with Ex-Serviceman)
Dependent
Brother of
Marital Status ( )
Married
Unmarried
Pensioner
Parent Polyclinic
(If not same as pensioner/
Family pension)
Yes
No
Permanent Disability ( )
Code
Blood Group
Name mentioned in Service/ Discharge Book (
)
Part II Order Published and
Yes
No
Yes
No
Copy/ Proof attached ( )
Aadhar Card No ______________________ PAN No : ___________________
Monthly Income _________________
Drug Allergy (if any)
Residential
Address
(If not same as pensioner/
Tehsil
Dist
Family pension)
State
Pin
Contact details
(a)
Mob
Tele No
(With STD code)
(b)
E-Mail ID :-
Name of
Dependent
(Maximum 20 Characters including space)
Sister
Citizenship (
)
Indian
NDG
Affix Recent
Date of Birth
(DD-MM-YYYY)
Colour Passport
Yes
No
size Photo of
Relationship
Employed ( )
(with Ex-Serviceman)
Dependent
Sister of
Marital Status ( )
Widow
Divorcee
Married
Unmarried
Pensioner
Parent Polyclinic
(If not same as pensioner/
Family pension)
No
Yes
No
Permanent Disability ( )
Code
Blood Group
Name mentioned in Service/ Discharge Book (
)
Part II Order Published and
Yes
No
Yes
No
Copy/ Proof attached ( )
Aadhar Card No _______________________ PAN No : ___________________
Monthly Income _________________
Drug Allergy (if any)
Residential
Address
(If not same as pensioner/
Tehsil
Dist
Family pension)
State
Pin
Contact details
(a)
Mob
Tele No
(With STD code)
(b)
E-Mail ID:-
Note :-
Code for Physical/permanent 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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