Health Card Employee Enrolment Form Page 4

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Aadhaar No
 Ortho
Blind
Hearing
M F
 Enrolment No
Mental
Percent:
Aadhaar No
 Ortho
Blind
Hearing
M F
 Enrolment No
Mental
Percent:
Aadhaar No
 Ortho
Blind
Hearing
M F
 Enrolment No
Mental
Percent:
DECLARATION*
The above information is true to the best of my knowledge. I agree to share my Aadhaar details of self and family with Government of Andhra
Pradesh. I am aware that declaration of wrong dependents will entail disciplinary action against me.
Employee’s signature:
Date:

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