EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS) APPLICATION FORM FOR MEMBERSHIP (REV 2015) (PLEASE FILL IN CAPITALS & IN BLUE INK) Applicant’s Application Regn No. Recent Colour Passport size Photograph in Place of Submission Civil Dress Category ( ) (a) Officer (b) JCO & Equivalent (c) OR & Equivalent HQ/Record Office HQ/Record To be filled by Stn PART I - PARTICULARS OF PENSIONER APPLICATION FOR ( ) Pensioner Family Pensioner Future Retiree SERVICE ( ) Army Navy Air Force CG DSC SFF Signature of Applicant 1. Service No 2. Rank (With prefix and suffix) (Abbreviated as per General Instructions) 3. (a) Name of Ex-Serviceman (Maximum 32 characters including spaces) (i) Regt/Corps/Ship/Base/Unit : _________________ (ii) Gender ( ) Male Female Indian NDG (iii) Citizenship ( ) Others (iv) Marital Status ( )Married/Unmarried/Divorce/Widow/Widower (v) Employed ( ) Yes No (vi) Monthly Income: __________________________ (b) Name of family Pensioner (if applicable) (i) Gender ( ) Male Female (ii) Category ( ) Officer/JCO & Equivalent/OR & Equivalent For family Pensioner only (iii) Employed ( ) Yes No (iv) Citizenship ( ) Indian NDG (v) Monthly income ____________ (c) Relationship with ESM ( ) Spouse/ Dependent Son/ Dependent Daughter/ Dependent Father/ Dependent Mother/ Dependent Brother / Dependent Sister (d) Date of Demise of Pensioner (DD-MM-YYYY) (e) Aadhar Card No __________________________________ (f) PAN No : __________________________________ 4. Date of Birth of Applicant (DD-MM-YYYY) Primary Member 5. Date of Commission/ Enrollment (DD-MM-YYYY) 6. Date of Retirement/ Discharge (DD-MM-YYYY) 7. Parent Polyclinic 8. Residential Address Tehsil Dist State Pin 9. Contact details (a) Telephone No (With STD code) (b) Mob No (c) E-Mail ID :- Family Pensioner 10. Type of Pension ( ) Normal Disability Family Speciman signature/lLeft 11. Pension Payment Order No (PPO No) thumb Impression of ESM/ (attach photo copy) 12. Name & Address of Banker/Treasury from where pension drawn 13. Pension Bank Account Number 14. Record Office 15. Drug Allergy (if any) 16. Blood Group Physical Disability ( ) Yes No Code (Optional) (Tick one as applicable) War Disability/Battle Casualty Disability ( ) Yes No Signature and stamp of authorising Officer of Station Headquarters/ Record Office. Note :- Para 16 code for Physical disability ,, 01 Blindness 06 Mental Retardation 02 Low Vision 07 Mental Illness 03 Leprosy – Cured person 08. Autism 04 Hearing Impairment 09. Cerebral Palsy 05 Loco motor disability 10 Multiple Disabilities 2 Application Regn No PART-II PARTICULARS OF DEPENDANTS Name of SPOUSE (Maximum 20 Characters including space) Gender ( ) Male Female Citizenship ( ) Indian NDG Affix Recent Colour Passport size Photo Date of Birth (DD-MM-YYYY) of SPOUSE of Pensioner Date of Marriage (DD-MM-YYYY) Parent Polyclinic (If not same as pensioner/ Family pension) Physical Disability( ) Yes No Code Employed( ) Yes No Monthly Income ____________ Aadhar Card No __________________________ PAN No : _______________________ Name Mentioned in Service/ Discharge Book ( ) Yes No Blood Group Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With STD code) (b) E Mail ID :- Name of Dependent FATHER (Maximum 20 Characters including Space) Citizenship ( ) Affix Recent Colour Indian NDG Passport size Photo Date of Birth (DD-MM-YYYY) of Dependent FATHER of Employed ( ) Pensioner ( ) Pensioner Yes No Yes No Yes No Whether dependent on applicant ( ) Monthly income ___________ Parent Polyclinic (If not same as pensioner/ Family pension) Name Mentioned in Service/Discharge Book ( ) Yes No Physical Disability ( ) Yes No Code Aadhar Card No __________________ PAN No : _______________ Blood Group Drug Allergy (if any) Optional Residential Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With STD code) (b) E Mail ID :- Name of Dependent MOTHER (Maximum 20 Characters including Space) Indian Citizenship ( ) NDG Affix Recent Colour Date of Birth (DD-MM-YYYY) Passport size Photo of Dependent Yes No Employed ( ) Yes No Pensioner ( ) MOTHER of Pensioner Whether dependent on applicant ( ) Yes No Monthly income _________ Parent Polyclinic (If not same as pensioner/ Family pension) No Name Mentioned in service/Discharge Book ( ) Yes No Physical Disability ( ) Yes Code Aadhar Card No____________________ PAN No :____________________ Blood Group Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With STD code) (b) E Mail ID :- Note :- Code for Physical disability ,, 01 Blindness 06 Mental Retardation 02 Low Vision 07 Mental Illness 03 Leprosy – Cured person 08. Autism 04 Hearing Impairment 09. Cerebral Palsy 05 Loco motor disability 10 Multiple Disabilities 3 Application Regn No PART-II PARTICULARS OF DEPENDANTS Name of Dependent (Maximum 20 Characters including space) CHILD Citizenship ( ) Indian NDG Affix Recent Colour Passport Date of Birth (DD-MM-YYYY) size Photo of Dependent Relationship (with Ex-Serviceman) Employed ( ) Yes No CHILD of Pensioner Divorcee Marital Status ( ) Married Unmarried Widow (For daughter only- if applicable) Parent Polyclinic (If not same as pensioner/ Family pension) Permanent Disability ( ) Yes No Code Blood Group Name Mentioned in Service/Discharge Book( ) Yes No Part II Order Published and Yes No Copy/ Proof attached ( ) Aadhar Card No ____________________ PAN No : ____________________ Monthly Income _________________ Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist Contact details State Pin (a) Tele No Mob (With STD code) (b) E-Mail ID :- Name of Dependent to be attached. necessary certificate ed, (Maximum 20 Characters including space) CHILD Citizenship ( ) Indian NDG Affix Recent Colour Passport Date of Birth (DD-MM-YYYY) size Photo of Dependent Relationship (with Ex-Serviceman) Employed ( ) Yes No CHILD of Widow Divorcee Pensioner Marital Status ( ) Married Unmarried (For daughter only- if applicable) Parent Polyclinic (If not same as pensioner/ Family pension) Permanent Disability ( ) Yes No Code Blood Group Name mentioned in Service/ Discharge Book ( ) Yes No Part II Order Published and Yes No Copy/ Proof attached ( ) case of child challeng mentally/physically In Aadhar Card No ___________________ PAN No : _____________________ Monthly Income _________________ Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist Contact details State Pin (a) Tele No Mob (With STD code) (b) E-Mail ID :- Name of Dependent ildren the photocopy this ESM to page. 2. CHILD (Maximum 20 Characters including space) Citizenship ( ) Indian NDG Affix Recent Colour Passport Date of Birth (DD-MM-YYYY) size Photo of Yes No Dependent Relationship (with Ex-Serviceman) Employed ( ) CHILD of Pensioner Marital Status ( ) Married Unmarried Widow Divorcee (For daughter only- if applicable) Parent Polyclinic (If not same as pensioner/ Family pension) Yes No Permanent Disability ( ) Code Blood Group 3. Attach Medical relevant document of Drug Allergy and (if any) Blood Group. Note : 1. In case of more than 1. In : case Note three ch Name mentioned in Service/ Discharge Book ( ) Yes No Part II Order Published and Yes No Copy/ Proof attached ( ) Aadhar Card No ____________________ PAN No :_____________________ Monthly Income _________________ Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With STD code) (b) E-Mail ID:- Note :- Code for Physical/permanent disability ,, 01 Blindness 06 Mental Retardation 02 Low Vision 07 Mental Illness 03 Leprosy – Cured person 08. Autism 04 Hearing Impairment 09. Cerebral Palsy 05 Loco motor disability 10 Multiple Disabilities 4 Name of Dependent (Maximum 20 Characters including space) Brother Citizenship ( ) Indian NDG Affix Recent Date of Birth (DD-MM-YYYY) Colour Passport Yes No size Photo of Relationship (with Ex-Serviceman) Employed ( ) Dependent Brother of Marital Status ( ) Married Unmarried Pensioner Parent Polyclinic (If not same as pensioner/ Family pension) Yes No Permanent Disability ( ) Code Blood Group Name mentioned in Service/ Discharge Book ( ) Yes No Part II Order Published and Yes No Copy/ Proof attached ( ) Aadhar Card No ______________________ PAN No : ___________________ Monthly Income _________________ Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With STD code) (b) E-Mail ID :- Name of Dependent (Maximum 20 Characters including space) Sister Citizenship ( ) Indian NDG Affix Recent Date of Birth (DD-MM-YYYY) Colour Passport Relationship (with Ex-Serviceman) Employed ( ) Yes No size Photo of Dependent Marital Status ( ) Married Unmarried Widow Divorcee Sister of Pensioner Parent Polyclinic (If not same as pensioner/ Family pension) Yes No No Permanent Disability ( ) Code Blood Group Name mentioned in Service/ Discharge Book ( ) Yes No Part II Order Published and Yes No Copy/ Proof attached ( ) Aadhar Card No _______________________ PAN No : ___________________ Monthly Income _________________ Drug Allergy (if any) Residential Optional Address (If not same as pensioner/ Family pension) Tehsil Dist State Pin Contact details (a) Tele No Mob (With