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1316096715467-Identity Cum Medical Card Application

This document contains a form for railway employees to fill out to request an identity card with medical information. The form requests information like the employee's name, P.F. account number, blood group, designation, office and station, date of birth, required medical treatments, residential address, family member details, PAN card number, photograph, and signatures.

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Mohan Vadivelu
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2K views

1316096715467-Identity Cum Medical Card Application

This document contains a form for railway employees to fill out to request an identity card with medical information. The form requests information like the employee's name, P.F. account number, blood group, designation, office and station, date of birth, required medical treatments, residential address, family member details, PAN card number, photograph, and signatures.

Uploaded by

Mohan Vadivelu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PARTICULARS REQUIRED FOR ISSUE OF IDENTITY – CUM MEDICAL CARD TO THE

SERVING RAILWAY EMPLOYEES (TO BE FILLED IN BLOCK LETTERS)


1. Name of the Officer/Employee (as per official records)

2. P. F. Account No:

3. Blood Group: 4. Designation :

5. Office& Station : 6.Department:

7. Date of Birth : (dd-mm-yyyy)


8. Medical Treatment required ( Please Tick as applicable )
BZA TEL OGL BTTR GDR EE RJY SLO TUI GDV BVRM STPM

9. Residential Address :
H.No/Railway Qtr.No.
Road/Street/Lane
City/Village
District PIN

10. Details of Family Members/ Dependents


S. Name of the dependent Relation Ship Date of Identification Marks
No Birth

1. Self

2. Spouse

3.

4.

5.

6.
11. PAN Card No: Stamp Size Photograph to be Pasted here
PF No: _______________
Photo

Signature of the Employee


Signature of the Forwarding
Supervisory official with Seal

For office use


Date of Receipt of Application: Date of Issue: ID Card No:

ID Card Received – Signature of the Employee :


(If outstation – Signature & Designation of the Receiving Staff)

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