arg nat = ‘Swasthya Sathi Kolkata-91, West Bengal Swasthya Bhawan ag 6 ofa same Re, oPoweN Ea (6) GN-29, Sec-V, Salt Lake, Bidhan Nagar, FORM-B (Application for enrollment under Swasthya Sathi) Application NO : _ OFFICE NAME & ADDRESS: (IF APPLICANT OR MEMBER IS EMPLOYED) bistRicT : DATE BLOCK/MUNICIPALITY:~ MINORITY STATUS : YES/NO PANCHAYAT CASTE : SCI ST/ OBC VILLAGE/WARD: DEPARTMENT (IF EMPLOYED) : RESIDENTIAL ADDRESS: CATEGORY : NAME OF THE APPLICANT FATHER'S NAME DO ANY MENBER OF THE FAMILY RECEIVE GOVT. ‘SPONSORED HEALTH INSURANCE / ASSURANCE : [Yes] RO] DO ANY MEMBER OF THE FAMILY RECEIVE MEDICAL [ALLOWANCE FROM GOVERNMENT: Gaye SL MEMBER NAME SEX | AGE | RELATION NO MOBILE NO. | KHADYASATHI ID NO. | AADHAAR NO ) 1 Beneficiary Jself es _afaalcaa sem MOTE ATH PT “SIGNATURE OF VERIFING OFFICER NAME: Bocas ces so oe) ee a a ts Fas in a Bor rer es aha ep TS ere LS a eS ‘BENEFIGARY SIGNATURE Fee BATS Sr00-084-Gor8 AACA AMAA FACS ANCA | RY 6 Mftata Feel ASA, oN HAA HAAR TATA AT THT Received Swasthya Sathi Application from Application NO: Signature DATE