To,
The Commandant,
SAP 12th BN.
Dabgram, Jalpaiguri.
(Through proper channel)
Sub: Prayer for new enrolment under WEST BENGAL HEALTH SCHEME 2008.
Respected Sir,
With due respect I, ………………………………………………………………………………………………
under your kind control, having GPF No ………..……………………………… would like to enrol myself
along with my dependent family members under WEST BENGAL HEALTH SCHEME w.e.f /
/2024. I hereby declare that all the family members are depending on me as per WBHS
provision. I further declare that all details have been furnished by me are true to the best of
my knowledge.
Date:
Enclo: As stated. Yours faithfully,
SAP 12th BN.
Dabgram, Jalpaiguri.
Details of Employee
(TO BE FILLED IN CAPITAL LETTERS ONLY)
First Name of Employee …………………………………………………………………………………………..
Middle & Last Name of Employee ……………………………………………………………………………
Date of Entry into Govt. Service…………………………………………………………………………………
Employee Date of Birth ………………………………………………………………………………………..
Marital Status …………………………………………………… Sex…………………………………….........
Employee Aadhaar Card No……………………………………………………………………………………….
Employee PAN Card No……………….……………………………………………………….......................
Employee HRMS ID …………………………………………………………………………………………………..
Mobile No…………………………………………………………………………………………………………………
Email Id…………………………………………………………………………………………………………………….
Permanent Address…………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
Employee Salary A/C No …………………………………………………………………………………………..
Employee Bank IFSC Code…………………………………………………………………………………………
Family / Beneficiaries Details (TO BE FILLED IN CAPITAL LETTERS ONLY)
Sl Monthly Blood
Name of Beneficiaries Date of Birth Age Relationship
No Income Group
1 SELF
Enclosure for Employees:-
Employee PAN & AADHAR card Xerox
ST
1 PAGE XEROX of Employee SALARY ACCOUNT Passbook.
All family members AADHAAR CARD Xerox / Birth Certificate for under 12 years.
BLOOD GROUP CERTIFICATE XEROX of all the family members
INCOME Certificate (not more than Rs. 5000/ Month) OR DEPENDENT CERTIFICATE By (Panchayet pradhan / Municipality/
Corporation ) for dependent family members.
Unmarried Certificate for Daughter/Sister By (Panchayet pradhan / Municipality/ Corporation)
Photo & Signature of the Beneficiaries:
Blood
Photo Signature Relation
Group
Signature with Date: ……………………………………………………………………………………………………………………………
