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Application Form for Joining RELHS-97 (Re-open) scheme & issue of Medical Card |
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Written by Administrator
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Tuesday, 14 July 2009 10:24 |
Application Form for Joining RELHS-97 (Re-open) scheme & issue of Medical Card DIVISIONAL PERSONNEL OFFICER,____________________________________________________________ Sir, Sub: Application for Joining RELHS-97 (Re-open) scheme & issue of Medical CardRefernce: railway board’s letter no. 2001/H/28/1/RELHS dated 16.3.2009In reference to letter of Railway Board cited above – vide which option to join RELHS – 97 has been re-opened & allowed up-to 31.3.2010 – I hereby opt to join & become member of RELHS-97 Scheme. Kindly issue me the Medical Card along with that of my following dependent family members. My service particulars and other information is as under: 1. name: _______________________________________________2. husband/father’s name: _______________________________________________3. designation: _______________________________________________4. office from Which retired: 5. grade/ rate of pay & pension_______________________________________________6. dob: _______________________________________________7. doa: _______________________________________________8. dor/dod: ___________________________________________9. nature of retirement: _____________________________10. m.r. no. & date: _____________________________________11. qualifying service: ________________________________12. address & telephone no: _______________________________________________13. fixed medical allowance (rs 100) opted or not: _________________________14. name of pension disbursing authority i.e. (bank) : _________________________________________________________ Accunt No. ______________________________________15. ppo no: _______________________________________________16. details of dependent family members for which medical card is to be issued: | date:place: | jointphotograph offamily | signatures of applicantname of applicantDesignationdor |
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declaration regarding “lock-in” period under RELHS-97(reopening of retired employees liberalised health scheme-1997) I, ……………………………………………………… s/o Sh ……………………………………… retired on …………………………….. as …………………………………. hereby declare that I am joining the above said scheme (RELHS-97) with full knowledge about the “LOCK IN” period. I will not submit any reimbursement claim for treatment taken in private and private recognised hospitals during the “LOCK IN” period (of 6 months); And also would not challenge the order of Railway Board in this effect in any court of law. I also declare that I shall fulfill all terms and conditions in the Railway Board’s Orders on RELHS – 97 as amended till now and bind with these instructions. | date:place: | signatures of applicantname of applicant …………………………designation/station ……………………….dor …………………………….. address …………………………………….…………………………………………………… |
……………………………………………………………………………………………………………………… DECLARATION OF FIXED MEDICAL ALLOWANCE REG.: JOINING OF retired employees liberalised health (REOPEN) scheme-1997 I hereby declare that, I am residing at ……………………………………………………………………… …………………………… & drawing my pension from the Bank ……………………………………………. …………………………… Under PPO no ………………………… & Bank A/c no …………………... ……… I am getting* / not getting* Rs 100 pm as fixed medical allowance since ………………………….. | date:place: | signatures of applicantname of applicant …………………………designation/station ……………………….dor …………………………….. address …………………………………….…………………………………………………… |
*Strike out whichever is not applicable
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