Central Government Health Scheme Beneficiaries Association

Regd. Under W.B. Societies Act, Regd.No. S/IL/73086 of 2010-2011

20-A/C Bhattacharjee Para, Barrackpore, Kolkata - 700 120

E-Mail : secycghsba2009@gmail.com

LIFE MEMBERSHP ENROLMENT FORM

To

The Secretary

Central Covt. Health Scheme Beneficiaries Association

20 A/C Bhattacharjee Para, Barrackpore, Kolkata - 700 120

 

 CGHS Card Number

Name of Dispensary

Sir,

I am a CGHS Card Holder and like to be a member of the CGHS Benefiriaries Association. My relevant details are given below.

I shall abide by the Rules and Regulations of the Association.

Thanking you,

Date :

Yours faithfully

1. Name ( In Capital Letters )

2. Address
3. Phone/Mobile No.
4. Blood Group

5. Date of Birth [ As per Employment Record]
6. Service Status

7. Employment Status
8. Name of the Central Govt. Office
9. No. of CGHS Beneficiaries (as per the CGHS Card/Cards)
10. 1st Beneficiary Name
11. 1st Beneficiary Card No.
12. 2nd Beneficiary Name
13. 2nd Beneficiary Card No.
14. 3rd Beneficiary Name
15. 3rd Beneficiary Card No.
16. 4th Beneficiary Name
17. 4th Beneficiary Card No.