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21.Forms Employees Pages

The document is an application form for enrolment under the West Bengal Health Scheme, 2008. It requires personal details of the government employee and their family members, along with a declaration to forgo the regular monthly medical allowance. The applicant must also agree to abide by the provisions of the scheme as they may change over time.

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11 views

21.Forms Employees Pages

The document is an application form for enrolment under the West Bengal Health Scheme, 2008. It requires personal details of the government employee and their family members, along with a declaration to forgo the regular monthly medical allowance. The applicant must also agree to abide by the provisions of the scheme as they may change over time.

Uploaded by

cyberspace741167
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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West Bengal Health Scheme, 2008

FORM A
Application for enrolment under the West Bengal Health Scheme, 2008.
(See sub-clause (1) of clause (4)

TO:
The ___________________________ (Cadre Controlling Authority/ Head of Office)

Sir,
I Shri/ Smt ___________________ (Designation) ____________________________
attached to _____________________ (office) under __________________________
(Department) do hereby opt for coming under the West Bengal Health Scheme, 2008
with effect from 1st day of ____________, _________.
(Month) (Year)

The particulars of the members of my family as defined in para 3(e) of the Scheme as
amended under notification no. 6722-F dt. 09.07.09 are as follows:

Name of Government Employee :


Designation :
Residential Address :

Date of birth :
Date of entry into Government Service :
Date of superannuation :
Present pay (Band pay + Grade pay) :
G.P.F. A/C No. :

Details of Family
Sl. NO: Name Date of Birth/ Relationship Monthly income,
Age if any
1. ____________________ ___________ __________ ______________
2. ____________________ ___________ __________ ______________
3. ____________________ ___________ __________ ______________
4. ____________________ ___________ __________ ______________
5. ____________________ ___________ __________ ______________

I do hereby declare that upon enrolment under the above scheme I shall forgo
the regular monthly medical allowance drawn by me as a part of salary.
I further declare that I shall abide by the provisions of the West Bengal Health
Scheme, 2008, as may be in force from time to time.

_____________________
Signature of the Applicant

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