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. Other Beneficiary Name [i]
11. Other Beneficiary Card No.[i]
12. Other Beneficiary Name[ii]
13. Other Beneficiary Card No.[ii]
14. Other Beneficiary Name[iii]
15. Other Beneficiary Card No.[iii]
16. Other Beneficiary Name[iv]
17. Other Beneficiary Card No.[iv]