APPLICATION FORM FOR MEDICAL ENTITLEMENT CARD
Ref No:
EMPLOYEES NAME:____________________________________________________________
FATHERS NAME:______________________________________________________________
DESIGNATION:__________________BPS-_____DIVN/UNIT____________________________
(NIC NADRA)_____________________________ Region_______________________________
DATE OF BIRTH________________ DATE OF JOINING PTCL___________________________
RESIDENTIAL ADDRESS:_______________________________________________________
PHONE: OFF:________________ RES:_______________MOB:_________________________
MAJOR PAST ILLNESS:_________________________________________________________
OLD EPI NO.__________________ NEW EPI NO.__________________
1 X 1 color
PPO NO. ___________________________ photo duly
(IF RETIRED) attested
Blood Group________________ after pasting
here.
Cost Center___________________
Signature of Employee
SPOUSE NAME:__________________________________________________________
SPOUSE FATHERS NAME:_________________________________________________
PAST ILLNESS:__________________________________________________________
DATE OF BIRTH:___________________________ 1 X 1 color
photo duly
CNIC NO._________________________________ attested
after pasting
________________ here.
Signature of Spouse
FATHERS NAME:__________________________________________________________
PAST ILLNESS:__________________________________________________________
DATE OF BIRTH:___________________________ 1 X 1 color
photo duly
CNIC NO._________________________________ attested
________________ after pasting
here.
Signature of Father
MOTHERS NAME:________________________________________________________
PAST ILLNESS:__________________________________________________________
DATE OF BIRTH:___________________________ 1 X 1 color
photo duly
CNIC NO._________________________________ attested
after pasting
________________ here.
Signature of Mother
Contact Details: Address: EFC I.I Chundrigar Road, Karachi Phone# 021-32632769; Email: efc.bzs@ptcl.net.pk 1
CHILDREN
1 X 1 color
photo duly
attested after
1.NAME .____________________________________________SEX:____________ pasting here.
DATE OF BIRTH:__________________CNIC/REGN. NO.____________________________
1 X 1 color
2.NAME :____________________________________________SEX:____________ photo duly
attested after
DATE OF BIRTH:_________________CNIC/REGN. NO.____________________________ pasting here.
1 X 1 color
photo duly
3.NAME :____________________________________________SEX:____________ attested after
pasting here.
DATE OF BIRTH:________________CNIC/REGN. NO._____________________________
1 X 1 color
photo duly
4.NAME :____________________________________________SEX:___________ attested after
pasting here.
DATE OF BIRTH:________________CNIC/REGN. NO.____________________________
Next of Kin (in case of emergency)
Name with relationship:_____________________________________________________________
Residential Address:________________________________________________________________
Phone No. Office:___________________________Residential:_____________________________
Certified that the above information is correct.
Following will be required for preparation of Medical Database Entitlement Card of every member:
a) 02 Blue Back Ground Recent photographs 1 X 1 for each family member.
b) Attested 01 photocopy of CNIC for self, spouse, parents and children above 18 years.
c) Attested 01 photocopy of Computerized Form B for children below 18 years of age.
d) Attested 01 photocopy of Departmental Card.
e) Attested 01 copy of Pension Book (if retired).
f) Contract Letter 01 copy Attested.
g) Non Marriage & Non Employement Certificate SIGNATURE OF EMPLOYEE
for daughters above age 25.
Date________________ ________________________
Verified through available record Signature of Manager ER & welfare
Verified through personal knowledge
Contact Details: Address: EFC I.I Chundrigar Road, Karachi Phone# 021-32632769; Email: efc.bzs@ptcl.net.pk 2
