UPGRADATION+OF+ECHS+SMART+CARD+-+APPL+FORM by keralaguest

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									12012/MSK/ROA/101011                                                      11 October 2010


                            NEW UPGRADED ECHS SMART CARD


         Existing ECHS Card holders need to obtain fresh ECHS Cards to enable medical facilities on
an all India basis wherever such Polyclinics / medical facilities are located. The new card will replace
the existing cards.

        Cost of up-graded ECHS Card is Rs. 135/- per Member Card through Bank Draft in favour of
dependent Regional Centre & to be deposited at Polyclinic/ Station HQ / Regional Centre. New
card(s) will be delivered at the polyclinic where the forms were deposited.

         The old cards including add on card(s) will be required for activation of new cards and
transfer of data. Wherever there are more than four members / dependents, use additional sheet as
page 2.

        You are advised to keep a photocopy of your application form duly receipted by the
Polyclinic / Station HQ / Regional Centre.

        This is for your information and action.
                                                                          Yours sincerely,



                                                                          (Major Satish Khanna)
     APPLICATION FORM FOR UPGRADATION OF ECHS SMART CARD
                  FOR EXISTING MEMBERS (CARD HOLDERS)
                                   (FILL UP ALL DETAILS IN BOLD LETTERS)

1.        Pensioner / Family Pensioner Name : ____________________________________________________
2.        Relationship : Self / Spouse / Father / Mother / Son / Daughter of : _____________________________
3.        Service No. ________________ Rank _____________ Name _________________________________
4.        Existing Card Regn No. _______________________________________________________________
5.        Force : Army / Navy / Air Force / Coast Guard /
          DSC / SFF (As Applicable)
6.        Details of Member / Dependents :-
           Ser.   Member / Dependent Name (with address      Relationship     Parent Polyclinic      Latest Colour Photo
           No.    and Tele No. with STD Code, if different                        Required             (Passport Size)
                            from existing one)                                                           with white
                                                                                                         background




                  UID No.
                  (if available)




                  UID No.
                  (if available)




                  UID No.
                  (if available)




                  UID No.
                  (if available)
7.        Total cards demanded:        ___________               8.         Amount (Rupees) : ________________
8.        Payment Details: DD No. ______________                 Date :     __ / __ / _______
                              Amount: ______________             Bank Name: ____________________________
9.        (a)      Physical Disability :       Yes / No                     Please attach relevant
          (b)      War Disability:             Yes / No.                    documentary proof


Date:                                                                                       (Signature of Applicant)

        Applicants to retain photocopy of this form duly receipted by Polyclinic / Stn HQ / Regional Centre
                                                                                                                 (PTO)
                                                           2

        In case any changes required to the existing details please specify, e.g. – change of parent polyclinic,
change of address and deletion of beneficiary due to death, marriage, over 25 age (son) & employment etc.

Ser.                     Changes Required                                           Reason
No.
1




2




3




4




5




Note:
    1.      The cost of upgraded ECHS Cards will be paid @ Rs. 135/- per card through DD in favour of
            dependent Regional Centre ECHS.
       2.   War disabled / battle casualty disabled veterans will be provided with white cards.
       3.   The application along with DD in favour of dependent Regional Centre may be deposited at Polyclinic/
            Station HQ / Regional Centre.
       4.   The new card(s) will be delivered at polyclinic where the forms were deposited.
       5.   The old cards including add on card(s) will be required for activation of new cards and transfer of data.
            On successful activation, the old card(s) will automatically be deactivated.
       6.   The O I/C Polyclinic on activation of new card will destroy the old card and will render a certificate to
            this effect to dependent Regional Centre for updating the record. A proper record will be maintained at
            Polyclinic to this effect.
       7.   In case of more than four members / dependents, use additional sheet of this form.

								
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