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Declaration Form

This document certifies an employee's employment details including position, years of service, pay grade, and dependent beneficiaries for issuing health cards. It lists the employee's name, department, and dependent names, dates of birth, gender, relationship, and Aadhaar numbers. The employee declares the information is true to the best of their knowledge for obtaining beneficiary health cards. The controlling officer verifies and certifies the information matches office records.

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426 views2 pages

Declaration Form

This document certifies an employee's employment details including position, years of service, pay grade, and dependent beneficiaries for issuing health cards. It lists the employee's name, department, and dependent names, dates of birth, gender, relationship, and Aadhaar numbers. The employee declares the information is true to the best of their knowledge for obtaining beneficiary health cards. The controlling officer verifies and certifies the information matches office records.

Uploaded by

TS MEESEVA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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DECLARATION BY THE EMPLOYER

This is to certify that Sri/Smt/Mr/Ms.

_________________________________ S/o/W/o/D/o____________________________ is working

as_______________ since ________ years in the office of ______________________ of

Department ________________ with a pay grade of ______________

The following are the dependent beneficiaries of the concerned employees

S.N Name of Date Gend Relations Marital Aadha


o the of er hip with status(Married/Unmarried/ r
Benefici Birth Employee Widow/Widower/Divorce numbe
ary r

Declaration of the Employee

I declare that the above information is true to best of my knowledge and submitting to
Aarogyasri Health Care Trust for issue of Health cards under beneficiary. I am liable for
disciplinary action for declaring ineligible family member if any as Dependents.

Employee
Signature

I certified that the above information is verified with office records and found correct
DDO/HOD/Controlling officer Signature with seal

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