Application form for Swasthya Sathi

District Block/Municipality* GP*

Ward No* Village* Para / Road Name
(For Municipality)
Department* Department
Category*
Office /School/ Sangha Name * Designation*
Office /School/ Sangha complete Address*
SHG Name (for SHG member)* SHG ID NRLM SHG ID DRDC:
Beneficiary Name* Father/Husband Name*

Caste*

Number *Mobile
Khadyasa
(Y/N) *Minority
(Y/N))Married
Sex*
yrs.)*Age (in
Name* Relation * with BPL URN Emp Aadhar number * Epic/Voter Signature*

thi ID or
SECC-ID
Status No, if of
(As per Aadhaar Card) Beneficiary RSBY loyee Card
(Y/N) beneficiary
enroll ID (if number
ed
any) *

Family Members: Beneficiary’s Spouse, Father, Mother, Father-in-law, Mother-in-law and dependent children
Caste: SC, ST, OBC, Others; Sex: M/F * …¢m Bh¢nÉL
*Signature of Institutional Head/ Block Office / Municipal Office
with seal Date
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