Ex-Servicemen Contributory Health Scheme (Echs) Application Form For Membership (Rev 2015) Page 7
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
177
Registration No ______________
RECEIPT FOR DOCUMENTS CUM TEMPORARY RECEIPT
EX SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS)
(USE BLUE INK ONLY)
1.
Received documents from No __________________Rank ____________ Name _________________________
towards application for membership of Ex-Servicemen Contributory Health Scheme (ECHS) :-
(a)
Application form (duly completed)
(b)
Photographs pasted at appropriate places.
(c)
Affidavit in original (duly attested).
(d)
Copy of MRO (where applicable).
(e)
Photocopy of PPO/Bankers certificate duly attested by bankers/treasury (where applicable).
(f)
Photocopy of service/discharge book /proof of dependants.
Category for Hospitalization ( )
2.
Private
Semi Private
General
3.
Force Type: _______________
4.
Regiment/Unit: ______________________
5.
Address with State and Pin Code:___________________________________________________________
6.
Mobile No: _______________ 7. Date of Birth: ________________ 8. Date of Retirement:________________
9.
Parent Polyclinic of Pensioner__________________10. Aadhar No:
VALID UPTO
11.
__________________
Place:
Office
Seal
Date:
Signature _________________
(
Stamp with Rank, Name & Appointment, Officer issuing-
)
Temporary Receipt in lieu of Smart Card
All photographs to be stamped by issuing Officer.
PENSIONER
SPOUSE
DEPENDENT
DEPENDENT
Name: _____________
Name: ______________
Name: ______________
Name: ______________
Date of Birth:________
Date of birth:_________
Date of birth:_________
Date of birth:_________
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
Name: _____________
Name: ______________
Name: ______________
Name: ______________
Date of Birth:________
Date of birth:_________
Date of birth:_________
Date of birth:_________
12.
ACTIVATION BY
[[
Place:
Signature _________________
Office
Seal
(
Stamp with Rank, Name & Appointment, OIC Parent Polyclinic)
Date
:
Notes:-
1.
This original receipt is required to be returned at the time of collection of Smart Card (s).
Receipt will not be destroyed. This will be filed along with the original Application Form.
2.
No Smart Card will be issued if this receipt in original is not produced.
3.
Record Office will retain this receipt after checking the Application Form for handing over to the
Individual if the ECHS card is not ready prior to his retirement.
The Original Receipt is valid up to a maximum of ONE YEAR from the date of issue.
4.
5.
Observation / complaints pertaining to Temporary Receipt (s) must be brought to issuing authority
within 07 days of receipt of the Card (s).
6.
Slip will be considered activated only after signatures of OIC Parent Polyclinic.
---------------------------------------------------------------------------------------------------------------------------------------
Pension Payment Order No (PPO No)
(Attach photocopy)
_________________
Date: ___________
Signature of ESM / Family Pensioner
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal