EMPLOYEE ENROLLMENT FORMPAGE NO 1 PERSONAL DETAILS(5 ) G.P.F
NO.(S f Hg el) RESIDING DISTRICT (hphpl Sm) DATE OF BIRTH(^ }
EMPLOYEE FIRST NAME( 3 } EMPLOYEE LASTNAME(LjQll Efd) SEX(m)
MARITAL STATUS(( 7) PERMANENT ADDRESS(7 } MOBILE NUMBER( *} EMAIL
ID( } RESIDENCE PHONE NUMBER(hpel *) IDENTITY PROOF ( 3} VOTER
CARD( } OR (Abh) PAN CARD ( ) IDENTITY PROOF NO. ( 3 el) ALREADY
ENROLLED IN HEALTH SCHEME? ( 7 30-Hl 5?) YES( )NO (e) ENTRY DATE OF
APPLICATION FOR ENROLLMENT (5l Lll ) OFFICE DETAILS ( } OFFICE
LOCATION TYPE(Agp Ahel f Ll) DEPARTMENT NAME(cll ej) DATE OF ENTRY
INTO GOVERNMENT SERVICE ( QLla 3 ) POSTING OFFICE DISTRICT OF
EMPLOYEE(Agpl SmNa Ahe)
EMPLOYEE OFFICE ADDRESS (Agpl WLe) SERVICE CADRE OF EMPLOYEE( }
DESIGNATION(} PAY BAND (haej) PAY SCALE( } GRADE PAY(3 } EMPLOYEE
ENROLLMENT FORMPAGE NO 2 BAND PAY(* } FAMILY DETAILS(flhll hhlZ)
TOTAL NO. OF MEMBERS (INCLUDING YOURSELF) (jV pcp, eS pq) NAME OF
THE BENEFICIARY(phdiNl ej) ****
--------------------------------------------- RELATION WITH THE
EMPLOYEE**** (l 7 * ) ---------------------------------------------
MONTHLY INCOME OF THE BENEFICIARY **** (l )
---------------------------------------------- CCA/HEAD OF OFFICE
LOCATION TYPE OF CCA/HO(7 3CCA/HO) DEPARTMENT NAME OF CCA/HO(CCA/HO
} CADRE TYPE OF CCA/HO ( 3} CADRE CONTROLLING AUTHORITY DESIGNATION
( @ V-Hl) DISTRICT WHERE DDO IS LOCATED(DDO 7 } DDOS TREASURY (DDO
Hl J} DDOS DEPARTMENT(DDO Hl 8} DRAWING & DISBURSING OFFICER(
DDO CODE ) (Y ,DDO ) BENEFICIARY WISE DETAILS(phdiN Aeku pQ) ****
SL. NO.( jL pwM) 1 NAME OF THE BENEFICIARY (l ) DATE OF BIRTH OF
THE BENEFICIARY (l ^ ) RELATION WITH THE EMPLOYEE ( l 7 * ) MONTHLY
INCOME OF THE BENEFICIARY (l ) SL. NO.(jL pwM) 2 NAME OF THE
BENEFICIARY(l ) DATE OF BIRTH OF THE BENEFICIARY (l ^ ) RELATION
WITH THE EMPLOYEE ( l 7 * ) MONTHLY INCOME OF THE BENEFICIARY (l )
SL. NO.(jL pwM) 3 NAME OF THE BENEFICIARY(l ) EMPLOYEE ENROLLMENT
FORMPAGE NO 3 DATE OF BIRTH OF THE BENEFICIARY (l ^ ) RELATION WITH
THE EMPLOYEE ( l 7 * ) MONTHLY INCOME OF THE BENEFICIARY (l ) SL.
NO. (jL pwM) 4 NAME OF THE BENEFICIARY (l ) DATE OF BIRTH OF THE
BENEFICIARY (l ^ ) RELATION WITH THE EMPLOYEE ( l 7 * ) MONTHLY
INCOME OF THE BENEFICIARY (l ) SL. NO.(jL pwM) 5 NAME OF THE
BENEFICIARY(l ) DATE OF BIRTH OF THE BENEFICIARY(l ^ ) RELATION
WITH THE EMPLOYEE ( l 7 * ) MONTHLY INCOME OF THE BENEFICIARY (l )
SL. NO. (jL pwM) 6 NAME OF THE BENEFICIARY(l ) DATE OF BIRTH OF THE
BENEFICIARY (l ^ ) RELATION WITH THE EMPLOYEE ( l 7 * ) MONTHLY
INCOME OF THE BENEFICIARY (l ) SL. NO.(jL pwM) 7 NAME OF THE
BENEFICIARY(l ) DATE OF BIRTH OF THE BENEFICIARY (l ^ ) RELATION
WITH THE EMPLOYEE ( l 7 * ) MONTHLY INCOME OF THE BENEFICIARY (l )
SL. NO. (jL pwM) 8 NAME OF THE BENEFICIARY (l ) DATE OF BIRTH OF
THE BENEFICIARY (l ^ ) RELATION WITH THE EMPLOYEE ( l 7 * ) MONTHLY
INCOME OF THE BENEFICIARY SL. NO. (jL pwM) 9 EMPLOYEE ENROLLMENT
FORMPAGE NO 4 NAME OF THE BENEFICIARY (l ) DATE OF BIRTH OF THE
BENEFICIARY (l ^ ) RELATION WITH THE EMPLOYEE ( l 7 * ) MONTHLY
INCOME OF THE BENEFICIARY (l )
