Form To Correct Errors in CGHS Card

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APPLICATION FOR CORRECTION OF ERROR IN PLASTIC CARD

Name of Beneficiary Ben. 10 No. Name of Family Member 1.

2. 3. 4. 5. 6. 7.

Dispensary Nature of Correction Correction Required Change of Ward From above 10 Nos. Ward to in rIo all the

Contact Telephone No

Ene!:

Photo Copy of Pay Slip & CGHS


10 Cards

Signature of Applicant

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