Health Card Employee Enrolment Form

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HEALTH CARD
EMPLOYEE ENROLMENT FORM
Employee code [as given by DTA]:
Tick the one you possess: Aadhaar Card Number Aadaar Enrolment Receipt Number
Aadhaar card number [12 digit]:
Aadhaarenrolment number [28 digit]:
PERSONAL DETAILS*
Name [as in Service Register]:
Sex: Male Female
Community:  SC  ST  BC  MIN.  OTHERS
Marital status:  SingleMarriedDivorced Widowed
Date of Birth [dd-mm-yyyy]:
Date of Joining service[dd-mm-yyyy]:
Disabled?  Yes  No
Disability:  Orthopaedic Visual Hearing Mental
Disability Percent:
RESIDENTIAL ADDRESS
House Number:
Street:
District:
Tick one:
Mandal/Municipality Name:
Village/Town/City name:
MandalMuncipality
Mobile Number [personal cell]:
Email:
OFFICE ADDRESS
House Number:
Street:
District:
Tick one:
Mandal/Municipality Name:
Village/Town/City name:
MandalMuncipality
Mobile Number [office cell if it exists]:
Mandal/Municipality Name:

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Parent category: Legal
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