a ‘es tg onter APPLICATION FOR EHS CARD ate or Se re ated ramtacsqaneemmamet tar parker Pease tick (which applabe and strikeout of) whichever nat apicabe, sexed iter fe opine fore EH cr a seers eh feat ge 5 elo new £5. Cardo replace ea: er tea ine ae ele 2. Mae othe opin pananaaae 2 ge ger eno (0) 2 catego Pak ubicheversspproprate (er sin CYoed [red has {serve Employee: Regdar[_[7Adhoe[—J/Tempora tus —}0n deputation] (att erate (Tote ee LJ Resident enor Reside [_—|nioresdet g (eyed rr i Reserch taffncladng Pn Shoe: (ore 1 Pensone (ema = = Ente Ca = mo (ow 2 Staten fa © othe (=| a Pease sei n= 3 onsenation 1. Fo 1 ae “nme Deparment Seton a a Nicaea met = 5. Pay nd 8 Grae par in Bn Ii resent Ba py nnn o. si ewe 6. asaya Penson: (eto 8 eee. rr wea) Persone ease mentoned contbtn fr EHS Bnet) Pemba sn 2.ofie Adress gb Resident Adress 8S (8) 5 Telephone number: (0)(a) eg (ae coca Senet SSCS Oaereneanitens eet eae osteo completion ftnure neat oferty esenehstat, —§ III | Pn Scholars & deputation stat as applabe: DID MIM VIF) WIT sacar seam Bere 12. Detar of Fai (Ce evar wt we fra a rs) [tea see deintion at [ge] fom befor ling up this Clon ‘No, | Mame olfemiy member [Relatonahp with | Dateof rth [Blood | (Vaio be fied by HS car Holder Group | Concemed Establishment Seto} Si | Rare weer Teac aia [Re [ee no roam sae nd ere evan RET a TP FEB 1B aealthepesonr whose nanesore gen above ae deenent won yaw Yes [—]o iN" prot ook wee t/t eee eh a ‘eiheer gee eso 1. "aac roo of thereat wou ke copy of C5 oem ears falon Crt ae sport ent Cased by cage Schoo riers ark ps ook ee. gon i ang ower gt et 6S 8 Hae Fl om one eH 9 Srv er Pease atach poo ependsney inept of ee of on] & deters] wh reference to dependency ter tried beret ope. 1a, ear pene (8) FH ea a FI 12 ioc a gre a ea 1M. paste one Photgaph ofeach member of dependent Family members (néwng Sf who are requed to te Ince for prostng£i. tenet pease nte tha he requene roid tam respec hs clus ‘Sos bln dot stove nine aque in clu 2 iom 50. Sho vata Val oa : for vate val vata. 1 nea sr RE ar & age em on geo {cray tat my fry members as above are whaly dependent one Wa eee (Pog et ar an A er See es He ah a a Hg a afer een ror Se ea one He sen, en ere re A er 8 mc fag wa eer undertake t tite nvedaey there any change independency citar of my family members neue inhi apcaton torn I alto and heather eome to know of he same, then the E'S fy abe to be withdrawn by the AIRS and fc appropriate author wile et tat any acto agate "aoa Sg 5 om he ag sre or ex He, el ey eB mimaet! | anderake to surender the EMS. cafe] on my. Iavng the AIMS on completion of tenure/ rotrementftermination/ resignation aon casing tobe ele HS bers ‘oer fhe er Rem Pe a wn era ee fr ep er ea vert! | cert that the Infrmatn furshed by me in hs appleation tas been ved 0 be correct and that no Information hasbeen concealed or ar boon mopresented and Ita bythe same ‘brew ta La. an he wir or eer rere; | ——— | cart that have made Es beneearycontrbon on yes/wholite lor pensioner anh] sion fe me to End: Poff Rltnship wlth dependents: eer nee Centra seer o ProofofresdeneeL—1/ Osabity create E) So a af oS Arete copies of PPO Last py Cortese (grant eon wot ora Sa eH TE OO {Was k ) whlenever i appeable ad stake otf) whichever not apple) (Progen soe ef ee 7)bere eCLAHATION Son Selah (8 fee nn mF in Ym "arab dere hat ny hr J re! atheroma rey on fae oth ay dependent vpon me anna he/she / they normaly rede wth neat eh {es hm are te settee sm eno snes ers Se m8 a eee ton 1 aso catty that father namely —-and mater sani se pendent on eater con rma source Peso / ary yrson and Penson eile of ONG ‘esnot ced to = per month ste ot of ares el! thee eo emo eg yi aoe eect ating son age esis uematre / wsrpoyed and whaly dependent on me een sentn tae gh gM brea bye a ee cary hat ny due age yess unmarie / unemployed nd wholy dependent ‘nen ecern tere et cu et rt nah Fv surender the HK Card ony leauge nat cn rns eremest/ enon eof penne eran (ier ams oe ew a {roxe venga oy THe coNCERNGD AOMIN. once) 1 oye eee fan ra en Pc spa hm, er Oe = Sin teVapelicfo tants Ege A iets eee 1. Thelfamation ihe by he appt as en aad rom ei rcords an fund toe rect ‘eommended thal 33 Hoc to be ted to Sim Pama Deseraton ioe waking nt eputmer secure grin rv nko dtr tm fn fe, sen Ae Rea 2.s\mance Son AIMS has bee nite sok raquo deduction vars ofthe EMS suction every tom ark ata fhe par seh gbu Be Ege. ee yor mee ef fo 4A. We eqieted to conser forthe fue of New EHS. photo Cas and EHS. Books to te bem) elo en ee Slgotr of th concern Adminitratie Otic (gue, whe arr sr EN) {To be filed by the EH.S Cel) ante oh Gage, sg Eopuge, ake gre ae ata 8 EHS. No, has been allotted by the applicant by the New E45. Cl aa tere wert (Ene, sete) Dealing Clerk (4S. Cel) Incharge (EMS al)INSTRUCTIONS Definition of Fai: (2) Husdond water st wie ony) (2) Dependant Parents /tep Mote nase of adoption, ony adopt & ot rel parents) (3) tfadopive shar he mare tan one wt the ft we ony. |) A female employee hs a hele to indude ether her dependent patets ar her dependent parent ~in low option eee an be changed only nce dir sere, {5} Gilden inducing legally adopted chileren, step children and chen taken as wards subject to the fling eondions 7 [= “Tile saris eang or aains the ag8 of 5 years WHEN ‘reser? W | Oavater Tl she stars eon or gas mavied rspecive othe ae lent whichever may beater? Tia | Sensing fam any permanant | respective of ai. 7 Staityof any Kd phseat or mental 35 defined bow [Dependent ivored/ abandoned or | hrespeciv of pnt separate tom thle hsband/ ‘domed daughters and dependent Snmarted/ahorcedsbandoned or Separated rom thir husband sosowed ters [aL oependent Minor bt ‘pte the age of aconing majo sabi issued by the competent authority, “Dealt wil be AS DEFNED IN SECTON 23) OF “THE PERSONS WH CISABLITES (EQUAL OPPORTUNITES, PROTECTION oF fick AND FUXL PARTICIPATION] ACT, 195 NO: 1 1998? WHICH I REPRODUCED BELOW: tt) “SABI” EARS (i SUNDNESS (iy towvsion (in LepRocy cone (0) ean maParent TM) Locomotor oisaBtry (oy Mena RrARoATION fw) MeNTALIINESS" Members of family (other shan spouse) whose income i es than Rs.3500/- per month ae tented dependents and are normaly resng with ES. benefiry. The Folowing Document are tobe enclosed (Proof Residence / Sty of dependents copy of ation Card / Election 0 /FassPot/Wemtty ‘arsed by Colege School Uniwrsty / Bank Ps ook, ec) (1) Proatotageofs0n (ut) attested copy of Disabity ertiete sued by Campetent Autor (ncse of dependent ‘on aged 25 and above) ‘For ensoner apphng for EMS. card fo the ist tne the folowing Adtonal Documents are requ (1) surrender Cerin of £15. Crd whe in servi, WW) Attest copies of PO Lat Py Cate ontibaton by Pensioners shouldbe made trough callanash/cheque/Sok Draft payable nove of the Director” Als, Hew Deh under due proces ofeoncernedEtablhrent Section Alls, New Dei,