Cashless id Card

DEPARTMENT OF SCHOOL EDUCATION HARYANA (GOVERNMENT OF HARYANA) Identity Card for Cashless Medical Policy (For Regular Emp./ Pensioner)

*PLEASE FILL THIS FORM IN CAPITAL LETTERS ONLY

(Office Copy/Emp. or Pensioner's Copy)

Secondary or Elementary/Primary Education

Date:

Details of Dependent Family Members

Employee ID & UCP Code-

PPO No. & File No.-

Resi Address

Memo No.

Name of Emp./Retiree

Father/Husband's Name-

Aadhar Card No.

Mobile No.

Email Id Sex

Blood Group

M

Sr. No

Name

Relation F/M/W S/D/H

Aadhar Card Number

Last Post Held

MM

100

Date of Birth

DD

Date of Joining

Date of Retirement

Date of Issuance

Date of Expiry

Office Address

Signature of Retiree/Emp (In Box)

Sign of Issuing Authority (In Box)

Gender M/F

If any type of cutting is there, same shall be attested separately with stamp & sign. of Issuing Authority, Seal Stamp of Issuing Authority (In Box) Otherwise this card is not valid.

In case of dependant/cependants this will be the responsibility of accepting authority to check first whether he/she qualifies as dependant or not as on date as per his/her age or other

medical conditions.

Affix a recent Post Card Size Photograph of Emp./ Pensioner with

dependents(if there are no one dependent on Emp. /Pensioner then

Affix a recent Passport Size Photograph of individual Emp./Pensioner)