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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