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This document is a receipt for documents submitted by Birendra Pathak towards applying for membership in the Ex-Servicemen Contributory Health Scheme (ECHS). It lists his personal details like pension payment order number, rank, force type, address, date of birth, retirement date. It also lists details of his spouse. The receipt is valid for six months from the date of issue and requires activation by the signature of the Officer in Charge of the parent polyclinic.

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Sarthak Pathak
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79 views2 pages

Index PDF

This document is a receipt for documents submitted by Birendra Pathak towards applying for membership in the Ex-Servicemen Contributory Health Scheme (ECHS). It lists his personal details like pension payment order number, rank, force type, address, date of birth, retirement date. It also lists details of his spouse. The receipt is valid for six months from the date of issue and requires activation by the signature of the Officer in Charge of the parent polyclinic.

Uploaded by

Sarthak Pathak
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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1/23/23, 10:45 PM https://echs.sourceinfosys.com/service/index_pdf.php?

content_id=2296952&content_tid=202364891&content_type=temp

AUTO GENERATED
Registration No : 0002296952
RECEIPT FOR DOCUMENTS CUM TEMPORARY RECEIPT EX SERVICEMEN CONTRIBUTORY
HEALTH SCHEME (ECHS)
Received documents from No 282093HRank WOName Birendra Pathak towards application for
1.
membership of Ex-Servicemen Contributory Health Scheme (ECHS) :-
Pension Payment Order No (PPO No) (Attach
2. 08/14/B/B 441/2002
photocopy)
3. Category of Ward Semi-Private
4. Force Type: Air Force 5. Regiment/Unit: Warrant Officer
Permanent Address with State and Pin Code: Current Address with State and Pin Code:
B42/43 Vaikunth Dham Society, Nr. Airforce Station, B42/43 Vaikunth Dham Society, Nr. Airforce
6.
Makarpura, Vadodara, Makarpura, Vadodara, Gujarat , Station, Makarpura, Vadodara, Makarpura,
390010 Vadodara, Gujarat , 390010
7. Mobile No: 9974117670 8. DOB: 01 Jul 1946 9. Date of Retirement: 30 Jun 2003
10. Parent Polyclinic of Pensioner Vadodara, MRO No. (if applicable)
11. Card Charges @ Rs. 177/- paid Rs. : 354 vide Transaction ID : 16654621840
12. Valid Upto : _________________

Primary Beneficiary Spouse

Name : Birendra Pathak Name : Prabha Devi Pathak


DOB : 01 Jul 1946 DOB : 15 Mar 1950
13. ACTIVATION BY
Signature _________________
Place: _____________
(Stamp with Rank, Name & Appointment,
Date: _____________
OIC Parent Polyclinic)
Notes :-
This original receipt is required to be returned at the time of collection of Smart Card (s). Receipt will
1.
not be destroyed. This will be filed along with the original Application Form.
No Smart Card will be issued if this receipt in original is not produced and final verification by
2.
Central Org ECHS.
Record Office will retain this receipt after checking the Application Form till retirement of the
3.
individual
Stoppage of FMA and deposition of contribution (MRO) as applicable to be ensured prior to issue of
4.
this receipt to pre 01 Apr 2003 retirees by Regional Centre ECHS.
This receipt will be issued only on verification of original PPO and discharge book for old retirees
5.
who are not in possession of old Cards.
6. The Original Receipt is valid up to a maximum of SIX MONTHS from the date of issue.
7. Slip will be considered activated only after signatures of OIC Parent Polyclinic.
8. Aadhar verification to be ensured by Polyclinics.
9. Old cards/ temp receipts will be returned.

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Date: 23 Jan 2023

Signature of ESM / Family Pensioner

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