Central Govt. Health Scheme oat Wor TaRey Var Application for errors in Plastic Card wanes ang A gfeah & fore onde Name of Beneficary: arene ar ATF Ben ID No.. Name of Family Member: oraril or year va Ge aa & Wee BT AH : Dispensary Nature of Error/Correction required afeenr eres / arbtre ape Contact Phone No..... wag BT A. Signature of Applicant Returned Old Plastic Card & Received New Card rn cies ars chern site var are wre fea @ RTE Signature of Applicant & rarINDIAN COUNCIL OF AGRICULTURAL RESEARCH ‘TRANSFER OF DISPENSARY Card No. 2 Name of the Govt. Servant g , 3 Telephone No. 5. Hinistry/Deptt //office : INDIAN COUNCIL OF AGRICULTURAL RESEARCH evious residential address d dispensary from which transferred. a s Residential address @ cure of Govt. Servant : sex Dispensary allotted by ¢ ssuing authority ture & Designation of + 5 uag authority with . ieiephone no. gaature of Medical Officer acharge Dispensary from 2 transferred Signature of Medical Officer = inckarge Dispensary to which ansferred.INDIAN COUNCIL OF AGRICULTURAL RESEARCH KRISHI BHAVAN : NEW DELHI APPLICATION FOR PERMANENT COHS INDEX/IDENTITY CARD 1. Name of the applicant : (in full 6 Block letters) 2. Designation 3. Name of the Section in which : working and Room No. and Telephone No. 4. Whether fresh appointment or on transfer from other Central Government Office 5. Date of joining the ICAR Hars. 6. Name of the previous office : (full postal address) 7, Whether he/she was issued : any CGHS Card/Temporary Family Permit, by his previous office. If its number of the Issuing Authority (in case the card was issued consequent on the earlier card having become mutilated or having been lost, this face may also be indicated). 8. Residential Address in Delhi : 8. Details of family members (including self) S.Nc. Name Relationship Signature of the applicant Date Forwarded to the Estt.III Section, ICAR for necessary acison. Signature of the forwarding officer Designation : Estt.I1! Section, ICARny TRANSFER OF DISPENSARY/sit3eTeta ST TATA ADDRESS CHANGE / Ud #@cf Astigaga, ars Ho /C.G.H.S. Card No want afat or am a cetera / Name/Tel. No. of the Govt. Servant wearer / feat / rater 3g Ministry/Deptt./Office ICAR rare ar gare Sen wa 8 ei ear & Previous residential address from which transferred 7ral aTarita Wai /New Residential Address wun) & FEM / Signature of Govt. Servant ant aet ard whens grat srafes sar ofeeera / New dispensary allotted by the issuing authority ard oA ae wae s eee wa Gea achat ara ae / Signature & Designation of issuing authority with telephone no. ae 8 wine afte gH steerer & want fafermarant & eT / Signature of Medical Officer Incharge Dispensary from which transferred: ‘Gel wirriata far ara 2 a shearers 3 wel Patera stent B eee / Signature of Medical Officer Incharge dispensary to which transferred:10. " Date INDIAN COUNCIL OF AGRICULTURAL RESEARCH KRISHI BHAWAN : NEW DELHI APPLICATION FOR FINAL PAYMENT OF GSLIS DUES Name of Applicant (In Capital Letters) Permanent Address in full Group No. Salary Grade Date of Birth Date of Appointment Date of Transfer to ICAR Hays. (in case of transfer only) Date of Retirement! Resignation/Death Date of entry into the GSLIS ‘Scheme Monthly contribution at the time of entry into the scheme Date of change(s) of category (details/dates of various promotions etc.) ‘Signature of Applicant. Designation/Relation. Permanent Address. Phone EmailAPPLICATION FORM FOR PERMISSION FOR GETTING TREATMENTS / INVESTIGATIONS DONE FROM CGHS RECOGNIZED PRIVATE HOSPITALS / DIAGNOSTIC CENTRES ] PARTICULARS, |"Name of CGHS Beneficiary & Card No | Designation of CGI 1S Beneficiary | ‘Basic Pay/Pension + Dearness Pay/Relief of CGHS Beneficiary [4 {Detail of the Patient and Relationship with the CGHS Benclicia Name of patient Relationship | CGHS Ca (3 | Name of Hospital / CGHS |Date of | Name(s) | Dispensary which has Prescription | required. prescribed Treatment | Investiga | Lt == ee - | ep] sy =| “Name and address of CGHS recognized Hospital / Diagnostic | | Centre from where | entfinvestigations are to be + I undertake that family member(s) as indicated above is/are dependent upon me and his/her/their income from all sources does not exceed to Rs.3500/- (us per instructions vide OM No. $.11015/10/2011-CGHS (P) dated 13.7.2011). If there is any diserepancy, 1 shall be fully responsible for the same, (‘strike off if not applicable) Note : Spouse does not come under this category i.e. income of Rs.3500/- Dated: __ Signature of Applicant Name of Applicant_ Designation Telephone No. P.S.: Kindly attach the photocopy of CGHS Card and prescription sliINDIAN COUNCIL OF AGRICULTURAL RESEARCH KRISHI BHAVAN !_NEH. DELHI DERAUREUCL REREAE SATE of NS RESPECT OF ANTES ELE DREN Reference O.M. No, 7-84/83-CéP Sec./CGHS-1777-2277 dated 19.12.87, i hereby declare that my father/mother namely ee _ _issare wholly/mainly dependent upon me and he/she/they normally reside with me in Delhi/New Delhi. z 1 also certify that the total monthly income cf j father/mother does not exceed my pay plus dearnes pay (where applicable) and that it dees not exces Rs3500/- per month. i 1 certify that my son namely te verarrs as un-employed and un-matried and wholly dependent on ne. rE sertify that my daughter/widow daughter namely age ——_____. years is Un-married and un-employed and wholiy dependent on me. z I certify that my wife/husband namely ee rn _ is ne employed in any Govt. Offices/Semi-Govt. and Organisation. 6 1 certify that my brother/sister/widow sister name!” years is un-married and un-employed and wholly dependent on me Signature of the applicantAPPLICATION FOR CGHS CARD FOR SERVING EMPLOYEES OF CENTRAL GOVERNMENT. 1. Name of the Applicant: er 2, Category ~ Departmental (—] Senices [—] { Please Tick Departmental f you are posted inthe Ministry of Health & Family Welfare DGHS / CGHS ) {Please Tick Services i you belong to any specific organized service } 3, Name of Department 4. Name of the Service. « er (in case of All Inia / Central Services = TAS/IPS. Er, ) 5, Designation coon EE] Ganetad Non Gazetted 5, Pay Band se PHOS PAY Grade Pay. (for Serving Employees) 7. offal Address 8. Residential Adcress: 9. Telephone Number: (0 ) (R) am 10. email 1D 11. Date of Superannuation: aoa cba Date” Monti Year 12, Ae you on Deputation (Central Deputaton) Yes / No 13, Ifyes,Ikely date completion of Deputation 14, Ke your services transferable to other cities: Yes/No 15. Detais of Family + Please se definton of Famly before filing us tis column _ Siho. | Name of Famiy member Name in Hind — | Relation shipto Bate of thw] LCGHS Card Halder* | (Compulsory) | Self | Toad Goap | opt "GH Please attach Proof of age of Persons menaned abovey 16. Are al the persons whose names are glven above ae dependant upon you and are resting with you? Yes/No {Please atach proof of ther staying with you , Ike copy of Ration Card / Election 1D / Pass Port / Identity Card issued by College / School / Unversity / Bank Pass Book yet, }(CGHS Card No while in service : ~~ APPLICATIOF a VERNMEN 1. Mime ofthe Applicant: 2. Category Pensioners (—) Others (Specify) — 3. Name of Department / Service fram where retired 4 Last Pay Basic Pension (ease Pendonar) 5. Resicantial Adress: 6. Teechone Number: ( 8) ay 7, email 1D 5. Date of Superanruavon: 3. Detalls cf Family 2 definion of Famly before fling up tis column} aan iy mera Wa (@ Please atach Proof of age of Persons mentioned above) 10, Are alt the persons whose names are glven above are dependant upon yau and ae residing with you? Yas / No (Pease attach aot oftheir staying with you , lke cary of Ration Cart / Election ID / Pass Port / Identity Card issued oy Gellage / Scrcol / University / Bank Pass Book, ec, }