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Form for Change of ECHS Polyclinic

Application Form for Change of Parent of Ex-servicemen Contributory Health Scheme Polyclinic:-

Appendix ‘A’

Polyclinic File ref:_____________________

Date:_____________________

INTIMATION: CHANGE OF PARENT POLYCLINIC
(Separate form to be raised for each card/copy to be sent to concerned Regional Centre)

To

OIC ECHS Polyclinic
_____________________________________

_____________________________________

_____________________________________(Address of Old Parent Polyclinic)

1. ECHS Card No _____________________________________

2. Name of ECHS beneficiary _____________________________________

3. Relationship with ECHS Member _____________________________________

4. No _____________________________________

5. Rank _____________________________________

6. Name of AFV _____________________________________

7. Old Parent Polyclinic _____________________________________

8. New Parent Polyclinic _____________________________________

9. Date of change of parent Polyclinic _____________________________________

10. Duration from ______________________________ to _________________________________

Declaration by Card Holder 
Certified above is true

Date:

(Sign. Of Card Holder)

Remarks of OIC Polyclinic
Verified details as above
Certified above is true

Date:

(Sign. Of OIC Polyclinic)

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COMMENTS

WORDPRESS: 1
  • Ishwar Singh Rana 1 year ago

    Sub: request to change of Parents Polyclinic one state to home state.
    Sir, my present polyclinic in Jamnagar station head quarter. Request for Transfer out and request for in. the new polyclinic in army base PALAMPUR HOLTA. my name is ISHWAR SINGH. EX INDIAN NAVY.CARD NO. AH 0000 0423 2038. WIFE NAME SUDERSHNA RANA.CARD NO. AH 0000 0423 2114.
    Therefore you are Requested kindly do the needful.

    Thanking You
    ISHWAR SINGH EX. INDIAN NAVY
    MOB.9427276627