Index card
Date
of Superanuation____________________
Govt.
of NCT of
Health & Family Welfare Deptt.
1.
Name & Designation of Government
Employee______________________________
(In full & Block Letters)_________________________________________________
2.
Department/Office in which
employee______________________________________
3.
Residential Address ___________________________________________________
________________________________________________
________________________________________________
4.
Nearest
____________________________________
5.
Deatails of Family Members ______________________________________________
“Family” includes only wife (or
Husband), children or Step Children, dependant, parents, minor Brother and
Sisters, Widowed and Widowed Sisters and nor other relations are entitled.
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Date of Birth |
Relationship |
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Self |
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PERFORMA FOR OPTION
I,
_____________________________________, hereby opt the
Scheme for providing medical facility to the employees/pensioner of Delhi
Government w.e.f_____________
I do not opt the Scheme as my wife/husband is a member of
C.G.H.S. She/He will avail medical
facilities under C.G.H.S. and he/she will get reimbursement of Medical
treatment in respect of family for special treatment.
My
wife/husband is employed/not employed in Govt.Deptt.
At_______________
She/He will not get
the reimbursement of spacial treatment from her/his
employer.
The contribution @ Rs.___p.m. May be deducted from my salary for the month of
___ _ Onwards.
D...................... Signature .................................
Name........................................
Designation..............................
Branch/Deptt.............................
.......................................
.......................................
List of Enclosures
1.Two
Unattested Passport size Photographs (self).
2.Attested
copy of Ration Card/Election Card/Residential proof.
3.Affidavit
regarding dependency of parents, if so. The monthly income of your parents from
any source, should also be mentioned in the affidavit. It be
also mentioned in the affidavit that your parents are getting any Medical
Allowance/ Facility from anywhere or not.
4.A
Declaration signed by the Officer/Official on a plain paper stating that :-
(i)
The Officer/Official is a regular employee of this office.
(ii)That a sum of Rs..... is
being deducted from his/her salary per month.
(iii) That the Officer/Official
is applying first time for this medial Card.
(iv) That the
Officer/ Officer's
spouse is working or not, if working than submit a certificate
from the office of your spouse that he/she is not claiming any Medical
Allowance/ Facility from his/ her Department.
5. Copy of Pay slip
of Last month.