‘Swasthya Sathi ‘Swasthya Bhawan GN-29, Sec-V, Salt Lake, Bidhan Nagar, Kolkata-91, West Bengal arg ara ary 6 fear Fat Hes, ATE AAA FORM-B (Application for enrollment under Swasthya Sathi) DISTRICT : ‘CANE NAME: ‘SERIALNO DATE BLOCK/MUNICIPALITY:- MINORITY STATUS : YES/NO PANCHAYAT :- CASTE : SC/ ST/ OBC VILLAGE/WARI DEPARTMENT (IF EMPLOYED) : RESIDENTIAL ADDRESS:- CATEGORY : NAME OF THE APPLICANT OFFICE NAME & ADDRESS: (IF APPLICANT OR MEMBER IS EMPLOYED) eee DO ANY MEMBER OF THE FAMILY RECEIVE GOVT. ‘SPONSORED HEALTH INSURANCE / ASSURANCE DOANY MEMBER OF THE FAMILY RECEIVE MEDICAL ALLOWANCE FROM GOVERNMENT Geos SL MEMBER NAME ‘SEX | AGE | RELATION | MOBILENO. | KHADYASATHIID NO.| AADHAAR NO. No (fAny) 1 Beneficiary Jselt w sol ale 10 coffee eet aA aT FA Bocas was et oes ee wa eae et a Ro PMA TE A A EPA ATE er ee wg afr af “SIGNATURE OF VERIFYING OFFICER NAME: {ERCIARY SIGNATURE Fa BUTS Sv00-08¢-Covs TNA CANT FACS ACA | ary 6 a Fatt Nes, MPoAaT As ATR NPAT HT CER | Received Swasthya Sathi Application from Application No : [ CAMP NAME ‘SERIALNO) DATE Signature