Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) Page 5
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175
Application Regn No
PART-III DETAILS OF MRO PAYMENT
(Serial 1 to 4 to be filled by only those whose contribution NOT deducted in PPO)
1.
Payment in full or in Installments (Tick as applicable)
Full
One
Two
Three
Exempted
2.
Bank
Branch
RBI
SBl
3.
MRO No
Date of Payment
4.
Amount
(Rupees)
PART-IV DETAILS OF PAYMENT FOR SMART CARDS
1.
Total Cards Demanded
2.
Amount (Rupees)
3.
Mode of payment
DD No
Date of Draft
Bank Name
Postal Order
IPO NO
Date
Ammount
Total
Date
(DD-MM-YYYY)
Note :- Faulty entries requiring subsequent correction will entail fresh cards being
(Signature of Applicant)
made on additional payment
PART-V TO BE FILLED BY STATION HEADQUARTERS/ RECORD OFFICE
1.
Basic Pension (Rupees)
2. Documents Checked and Receipt issued ( )
Yes
3.
Payment Received for Smart Cards
Rs.
4.
Category for Hospitalisation
Private
Semi-Private
General
5.
Date of Receipt of Application from/
Date of Retirement of Future Retiree
6.
Date application forwarded
(Signature and Stamp of Station
to Regional Centre
Headquarters/ Record Office)
PART-VI TO BE FILLED BY REGIONAL CENTRE ECHS
1.
Date of Receipt of Application Form
2.
Date application forwarded to Vendor
Checked by
Verified by
(Initials & No)
(Initials & No)
Signature and Stamp of
Authorised Offr
SMART CARD DETAILS (to be filled on receipt from vendor)
1.
Date of Receipt of Smart Card(s)
2.
ECHS No.
(Mentioned in Smart Card)
3.
No of Smart Card(s) issued ( )
One
Two
Three
Five
Four
Six
(a)
Dispatched to
(Station HQ/ Record Office/Individual)
(b)
Date of Dispatch
Initials
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