, ." (..

The following stages are involved in issue of CGHS pensioner card:-On the 1st visit the pensioneris requested to fill up the applicationfonn and enclose thefollowingdocuments for scrutiny

1. Copy of pensionpaper order,2. Surrendercertificateof in serviceCGHScard,3. Proof of residentialaddress,4. Copy of lastpay certificate.

If the pension paper is found in order and eligible for CGRS facilities, he is issued cardfonnats (two index card and one CGHS card fonn) to be filled up and the amount payable byhimby bank draft as per the PPO.

Attested copy ofPPO and last pay certificateGroup photo in triplicate whose names are to be enclos"edin CGRS card includingdependent children.

3. Requisite bank draft payable to the Pay & Account Officer, CGRS, New Delhi4. Surrender certificateof in service CGHS card,5. Photocopy of residentialproof

Normallythese documents and bank drafts are submitted on the ~d visit of the pensioner.

He is requested to enclose the following documents with the application from and cardformat:-

1.2.

The documents are processed, entered into the ledger and put up to the AdministrativeOfficer for signature either on the same day"or next working day, which are signed and sentback to card section on the same day for issu"e.

The beneficiarycan collect the card on the 300day of depositing the documents.

..

~ ~it ~-fifCt~ mr"(1 itwoRTi<f.

ON'£..Y FOR CENTRAL GOVT. PBNSIONERS

~tn: ~~ (~o«o~qrOl:TTo)The Additional Director (CGHS)

~;fo 526, s<r11if~ tt«'f" f.,m,f.Aiur ~, <ri:f~~Room No, 526, te' Wing, 5th Floor ~

Nirman Bhawan, New Delh i

f~t1'iDated

~ :4,,~o~<Tfo~o ifuor~<t>fi~ ~~ q~ I

sub :-Ap!,lication for Ce'!1tr\1.tGovernment Health Scheme Pensioner Card.

~~T~,sir,

$tflfT~ Q,Ct ~ ~f"( :t ~<il ~~ f~f $l£rn f.t+.,~ ~ 31f~ ~I~., if;Wtir~ r:p; ~~ ~ ~ ~ ~1<f ~~T"( ~ ~ 'if i if mf'l'Vr f.t;m \iiW;I'"

1 alongwith the members of my family whose particulars are given bekw may please be admittedto CORS on payment of subscription on the basis of last pay drawn/pension.

1. ~;pr~""" . . . . . . . . ., ., ..,. .. ... . .. . . . . ., . . . . . . . . . . . . . .. ..Name of the Pensioner. . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

~. . . . , . . . . . . . . . . . .

::..- &I!r~ /ft''''' ,.::","".::!r:c:r'. . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . .. .2. ~"I1 I"~'" '"1. "'. Q.", . ......................Date of Retirement/I>eath. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. . . . . . . . . . . . . . . .

.

3. f.:rcI'm~~ <tit ~ ~f' . . . . . . . . . . . . . . . . . . . , ... . . . . . . . . . . . . . . . . . . . . .. ..............Resident:ial Address . . . . . . . . . . . . . . . . . . . . . . . .. .

. ........................

~;t;:rm~~~ ,.

,. J" . . . . ., . .. . . . .. . . . . . . . . .. . .

... ~ "" . . . . . . . . . . . . . .

Telephone N0.. if anY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., .. .0 I. I

5. ~\'Pf/fcr~ ~t ~ ~ f.rcrff~ i' . . . . . . . . . . . . . ..,... . . . . . . . . . . . . . . . . . . . . . . . , . . . ,q. . . . . . . . . . . . "," . . I . . . I . . . . . . . I . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . .

MinistrY jDepartment from wh icb retired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . ..', , ,.

( 1)

.. .

2

6. 'I." 1("". . . . . . . . . . . . . . . . . . . . . . . . . . . ." . . . . . . . . . . . . . . . . . . . . . . . . . . .Basic pension.. . . ..

' ... (~ I )7. "'" ,i'<'Iif"'"'''' !!T''';;< <\!{ \~. '11!' ., . . ., . . . . . .' . . . . . . . . . . . . . . : . . . . . .

Wh,ther in ",dpt of familYpension (yes/No) .' .. .' . .

s. ""'" ~mI . . . .' . . . . . . . . . . . . . . . . . . . . . ..- . . . . . .. ~ ~ ....p'nsion payment()rder N° ., . ..,

9. 1rf!-""'''' ~Fr <t q~ 'If<ij1!." it<!,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MS t B;sie PaY dr':.wn befor~ r,tiremen t. . . . . . . . . . . . . . . . . ... . .. . . . . . . . . .

".. .

1O. qf<:ql'( ~ q~~T ~ 3T~ qf"(CTT'(qrr f~ :Details of famUYaccording '0 the dofinition of the familY:

.-----------..------

- ---.

--'---'-'--

GI;:~ftTf1f

Date of Birth

~'~8'Relationsbipwiththe A[;plicarll

:---

1.

2.

3.

4-

5.

6.

7.

i.

------~" """ ..: Of{{\:f,rIr,iflf\lf.tll,if~ troT,;m.m ~ r u~ ""'" ~~ ' .I.hall a.i.. 1>1t\" rules and regulations and mod ifieation of 1M ,m"ce whicb 1><i"

thne to th.e.

10.

-

/3

ii:, " ,..,... "- , . . . . '. . . . ., . . ." '. .'. . . . . . ." . '~M'oT ~ srf~ ~

. .'.. ,~ f<t>q' srr.: ~ 3fTfJ5!'~~;pT fcr~~;rnr 3trf~tt<i ~3 ~ fi{liTtr-TT~ ~t:~'i {i q€t 'R: ~ m!!f ~ ,,~f ,J,. . . . . . . . . . . . . . . . . . . . . . .'. .'. .'. . . .'. .-. _~. _ _ _ _ .-.8olemulyaffirm that I and my dePendents

'whosenamesare givenon pre-Pageare residing with me at the address mentionedat S1. No.3 on. . pre-page.

~ ~(\~ "ro "~,, 1f;Ti~Ct 10 <rt (~ft"f;; q'1f;:('r)!J;fT~i1;ftt~~ Tfr~~r ':f11rto 3RftT ~ ~.. , " . . . .-. .

" . . .. ' ...~ CJ;'TofcpF'a' ~-.: 'f<:-rt~. '" . . ~_.. ..<it ~ ~ ~ it\;f'JfT~Cfi'I1{ ~;q~ ~r!!f~ ~~ ~ I

I am depositing the contribution of Rs. . .'. _ _ _ _ _ _ .'.. . . .(Rupee &__. . . . .. . . .'. . . . . . . . , . . . . . .),for 10 years (WHOLE LIFE) or for. ... .-..'. . . ..._ _ ",years in the form of Bank Draft No....... -. . . . . .dt. . . . . . . . .'. . . . .name of the bank. . .'. .__ _ _ _for the month of ending period J'unefDecember

,for CGRS Card.

ar~ ~ ~~Signatureof tbe applicant

f~;;t<r.:

Da,te:

< i!~Qi;;<:;rthr q'~~<fi!fr "{,:jfi:f~tf"3ifa-'BTi\'rnr mmfcmr~~ ~~ )-(Signatureto be attested by Notary Public or GazettedOtBcer)

;f'<f~'t~m i f'fi ~01~"':'ff"~" 'lit W'<rill"t~5 ~~ ~ atRTit' 3fq-~ ifw'f/3if(fQ 1<:(1''r;' art'CfT1:~ ~ ~'3Th ~1ffc!!,if Tf~ f'1)~ '):ff!fliP:: 'fiT~f \!f'fi;1'<f~ f~~ 31''t,)~ ;r@ ~~';rT I

I h~reby u..I1r.1~rt&kcto contrib!1te on Un basis of my p~l1si(}lt/Ia5tpay drawll to avail COHSfaciHtks aDd wHl not request for a change in f8t1ire.

Jfi~t~5;ignature of the applicant

"

ilcmra ~Documents Required

1. ~;r ~ar.r ~ 3f11:ot~ iraTiSflfTvrIWfqir!) 'liNT(~ifqi'fiti6')Attested copies of pension payment order and last paYCertificate

2. a'nr ~q qj1i'\'(f:,..t ~ ~o~o~ CfTc~ToCfniif ~fnrf~ ~it~. (~q 1fi1it~i~~fIt;iJ~ ~ ~~Group photo in triplicate (Whose names are to be included in tbe CGHS pensioner C3rd (withfoU':'attestation).

3. 3Jff~ ifG~(atfcmfila ~ ~"()\;l~ f~~f 1ffar11tCf1it {f) ,Dependantchildren(unmarried ~nd unemPloyedirrespective of age).

4 , ::i1l\' ~~ ~ 'tmrTW~ ~ ~T 'R!IT~ 4iT~~ ~ ~'lTfIf.ni~ it srr~: 9. 3 (1qci. 'ij l{iqp J2. 30

~ (Ai ~ ~1ft I

Alt type of enquiries/depositing/collection of cards wiIJ be between 9.30 A.M. to 12.30 PM. on a1l

working daYs, .

5 . ~~ f<i\'~ft11'1'"(f~~1'1:fWQi?'C¥i~ JT~G if~T \if) f~ "'(If{ aih: iJtiJ ~ftr'tirt1 it;dl' c ro dfTo, ~ ~r" ~ ;;TB.

~ ~ :qTf~ I

paYmentsouldbe made bY Bank Draft of Nationalised 'B3n1cwbidl shruM te paYa1.'k in f"v..ur of"PaY and Account Officer CGHS, New Delhi".

6. ~~ ~ ~'tuif <i\'Tto«omo~)ocmi Gf;fT~ii lIT~-qef 1

surrender Certificate of CORS card in service.

7 . 311<fT~'Nsrmor~ m srfuI

PhotocoPY of Residential proof.

!{~q)-308 ~~«'ZOO3-13-10-2003-81000MGIPP-308 CGHS/2Q03-13-tQ-2003- 8,000

p

!/\'6" 0I1tim{~.. A" Di~pen!qU'7 ... 1"10;r;{D:6D~n:;a,;y

'fH~ ij'~ifjt~/GOVER...l'.:rMENiOl~ INDt.\.

«~~ ~':'( qf~411; ,,/f;;TiUJmr!~/l\iA.NjSJRY · iJ HL~A!.1I'!&. fA:.fr.n '\'Ij:~;...i:'ARE~f'!ii'Q (:f(~~ ~r.r.~ zr"):t!~t

.C.h"NTRALGO"f.RN"mN:r H.&'\L'rH SCHEME

-I. q.;r.in: <fit<fr! h-:! ~,~ fl{t.C!~t(t it)... 1".." ... H H.. _,J',. m.: of Pl'fJ<ioJl"(In fu,1) ._

2. ~~/f~mtJ/~rqt~ 'it~ ~ fitfYf~{~;p,",:~,. .. ". ... ~....Mltlililrjll)tpafvlll'J1[/Ollke from whlcb fC!4ed .

3. q~ 'i'T't~i/R.c.liiQI:',tlalAdJlo>iII . . . . . . . .

'1"...-

" , 111... . .. .. . .. 0 .. .

JnnVl"'U:CERT1FICL\TB

rt ~~r.t"(r "f)f'f"5cr1;~' ~fir; ~I OOI~ d!:i:lan:tbat 2

(tV) ~'t fimr/?r{'i JlliH ~<T<tiriff11' , ''t~(f;/~fT: ~ q~

OfTf.~;;; ~ iIfj'{ % srr<f:' . . . .. .. . . . . . .. . . . .. . .ij ~ <It'll ~{! ~ ! ~l rmr

~rar (.t iffi'-Tf:i~ft w ~<f,r'{~ :500J~ tqo « arts'i> rr:' ~ It:a) MyMber/motl',ername,y.. ... . .. . .. ' ... .Jsiare wboily,matuly ckr.etldr;:ut

upon me ,md Iha~he/she norm;tl1yrCI;-dcwith m., in ............Tb"ltotal ~Dcr-lneof my iather/mother d,)e,~not ~cce<r~. son.!. t,'er rc,Obt!.\}:r,)ma.;1lour::.~.

'\ I?r' irUl}er!11Pii',f1.11r 1111' . . ;. ,.. '13fT;'. e. . . . . . 'inl\tftm:, i\'{ ;;oJ1~1_. ~ 6

if,~ rp: 3rrf'-f(t ~I . .

(11 I\-{y!iOO(llIi'lfJrbrother. .. . .. ... . .. . e . . .. . . . . ar;a. . , ... . .. ".. ..., J'~- n is unemplo)ocdaud wbcl!y ,fcp,'udeot up;:m O'e.

(rr) $\--.:1~:ft.'orfif'/~~qT~i'r' · . . . .. an7i'. . . . .. .m,nfi{a-ihf.5{;rp:e :111'<:~-it':'f;'! .of3fT~~ ~I

(,) My,J;\u[\h1erl,\~tl' o~,j dllll~h~er. . . . . . .. ... eo'"" . .,. .!l.ge... ., , . , ,. . , . , . .14 ulJU1arfh:lI/l1n~~.lI"I~..yed ;lUrj w)1o.lIy tlep..:odc\lt on ID\:.

(~~) it ''J&~r;r-~~1ft on~!T'f>H if {t~ q~/lH oFt{ fq.~ft l:fial1[ f'I' ~rf ~r.t 'tt~mf1;fiif't.f<fiT~rl:ffiCfi~ if,f ~qif ~o r ~,

(d) J ,;!,d~rt,t:t~ to mlTeD,ier thc J(t~n:jty C.UlI to tl1~ IssuIng ~1.1:bNity in ca,'e tbe 3/l1111)hino.t l.;;Jl':'e';i (or' all}' rCason whalsofar. ,

;tT<f>rfr CfiiT'CiTU ~ ~~(iT~'{'/ort.~Ifi1fifWA. . . . . . . . , . . ,,'. . e.. . . . . .. . .S!gaalure,l rhumb IIt'PTCSsioll of G~)vt. e:l.ploY~e

afrEfa~ «" mt: tfm. . , . . . . . . , . . . . . . . . . . . . . . . . . . . ' . . . . . . . . .Dl~pe[\.}ary No, Ii Name

if.'li \ifnl ~it <t) 1.ir~)~ . . . e. . . . . . . . . . . . . . . , . . . . . , . . ,Date on which Idc.ntHy n.rd is!iUi:-:l. .

Sfillf~CTfCfi.:n3fTen~fCfi~!/f;fl q;;rp/'nt"iTJ'f q'~, \{;p:f-~ ~ ~.~]; 1 .'1. :11.:.

~-(, f~'~ iff{f<\i.fq'f~" arr~m1; iIT'!~1T~~n1 'ti'\it 'f(; S1rfa-'f1Tit;li~; ;.~!~ 't}{m 11'~~sih ~);.{i$l<iiT'{~ Gff1;rff;lrTtfli'T, , .

Certified that tho Indcx:!dcntity Card hasj1rnvo been duly scrutfnlse.i by '.bfJ Is~ulogAut:lorlty a.~d correcdy Issued Ie accordance witJ:1the l'Qi~~& )Cde.~ I~:uel": b~ the M!ni..tryof HealtbfrOffi tlm:: 10 tlll2e

crr..iwr {i1~1.: IJ[tir$~~ ~,~ OIfa;r,ritr5fl~F,!'a.~~1 'i'tOlli~~Slam!, Signature & Di.!I~n{itI(l"l1fTnu/!1gAit"'1J1liy

!fmij'T;!.;rl,-t54!Uto::)f'fcf~'if')~U'" tri fon"i;!Tj96'-',-lO-2-97-- 1,5(},OO\). .MGIPNrk-::E4 ~':G:H:S~RC~ 'p~,lhiT96--jO::i=-9-i'::-jj"II,ooo'.-----------..---