Health Card Employee Enrolment Form Page 3

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Aadhaarenrolment receipt with your name and enrolment number clearly visible if you are giving the Aadhaar enrolment number.
DoB Certificate: Scan the Date of birth certificate if the dependent family member is less than 5 years of age.
Disabled Certificate: Scan disability certificate if family member is disabled.
DEPENDENT FAMILY MEMBER DETAILS
DoB
Sex
AadhaarNumber
Relationship
Name
Disability
(dd-mm-
(tick one)
(tick one and write the number)
yyyy)
Aadhaar No
 Ortho
Blind
Hearing
M F
 Enrolment No
Mental
Percent:
Whether your spouse is a Government Employee / Pensioner? Yes No
Employee / Pensioner id:
Posting Details:
Head Of the Department:
District of Posting :
DDO Code [write the DDO code of your Drawing and Disbursing Officer given by DTA]:
Designation:
Pay Details:
Pay Source:
PRC:
Pay Grade:
Current Pay:
Aadhaar No
 Ortho
Blind
Hearing
M F
 Enrolment No
Mental
Percent:

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