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PHOTOGRAPH

PESTING
(In Duplicate)
GOVERNMENT OF NCT OF DELHI
OFFICE OF THE DEPUTY DIRECTOR OF EDUCATION (SOUTH EAST)
DISTRICT: SOUTH EAST ZONE: 25

APPLICATON FOR ISSUE OF MEDICAL FACILITY CARD

Name of the Beneficiary & ID :- .........................................................................................................

Designation & Dept. :- …………………………………………………………………………

Place of Posting & working :- ………………………………………………………………………….

Date of Birth :- ..........................................................................

Date of Appointment :- ..........................................................................

Date of Retirement: - ..........................................................................

Basic Pay Last Drawn : - ..........................................................................

Basic Pension (In Case of Retirement) :- ..........................................................................

Revised Basic Pension: - ..............................................................................................

Residential Address: - ..........................................................................................................

……………………………………………………………………………………………………….

Nearest Delhi Government Dispensary :- ………………………………………………………….

Details of Family as per the Service Record :-

S.N. Name of Beneficiary & Family Members Date of Birth Relationship with the
Beneficiary

13. Amount of Subscription based on Gr. Pay being deducted from pay per month regularly @ Rs. ……………….
Per month in case of service employees.

14. Lumsum amount deposited vide TR-V No. Dt. ......……… Rs…………….. and bank Challan
no.……………… dated …………….. in case of retired employees.

Signature of the Beneficiary
PHONE No.-
Counter signed of Principal/HOS

PHOTOGRAPH PESTING (In Duplicate) .