APPLICATION FORM OF INSERVICE GOVERNMENT EMPLOYEE

UNDER WEST BENGAL HEALTH FOR ALL EMPLOYEES AND PENSIONERS CASHLESS MEDICAL
TREATMENT SCHEME, 2014
DDO-Officer-in-Charge,R.R.K. Govt. Polytechnic,Ramgarh,Jhargram, ( MIETEA003 ) (DRAWING AND
DISBURSING OFFICER) DEPARTMENT OF DDO-TECHNICAL EDUCATION & TRAINING DEPARTMENT
DETAILS OF GOVERNMENT EMPLOYEE: WB/EMP/02/000324846
1. NAME OF THE GOVERNMENT EMPLOYEE: SK SAFIKUL ALAM
2. DESIGNATION: LECTURER

3. ADDRESS: C/O SK MD ILIYAS,VILL BANIYA,PO D M GHAT, PS

SHYAMPUR,DIST HOWRAH, WB 711301
4. DATE OF BIRTH: 02/01/1978

5. MOBILE NO: 7679236263

6.PAN/VOTER CARD NUMBER: BBGPS0530K

NONGPF/WB/20191013121854940
7. IDENTIFICATION NUMBER:

8. EMAIL ID (IF ANY): mail2safikul@gmail.com

9. MARRIED OR UNMARRIED: MARRIED

10. DATE OF ENROLMENT: 01/11/2019

11. NAME OF THE EMPLOYER (H/O): JOINT SECRETARY

12. OFFICE ADDRESS: RAJA RANJIT KISHORE GOVT POLYTECHNIC

DETAILS OF EMPLOYEE WITH THEIR ELIGIBLE FAMILY MEMBERS:

SL NO. Name DOB Relationship ID No PHOTO SIGNATURE
1 SK SAFIKUL ALAM 02/01/1978 SELF NONGPF/WB/2019101
3121854940/1/5

2 SK RAIQA ALAM 22/12/2008 UNMARRIED NONGPF/WB/2019101

DAUGHTER 3121854940/2/5

3 SAHINA BANU 09/08/1979 WIFE NONGPF/WB/2019101

3121854940/3/5

1/28/2020 9:23:01 AM Signature of the Applicant

N.B. Please take two copies of print out of the Application Form with scan photo & signature of all beneficiaries as
generated from the system to the DDO for verification.In case of a child below twelve years, natural guardian's scan
signature with child's photograph is required.
 SL NO. Name DOB Relationship ID No PHOTO SIGNATURE
4 SK MD ILIYAS 15/09/1952 FATHER NONGPF/WB/2019101
3121854940/4/5

5 SANOYARA BEGAM 03/01/1958 MOTHER NONGPF/WB/2019101

3121854940/5/5

1. I, HEREBY DECLARE THAT THE THE STATEMENTS MADE IN THE APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
2. I FURTHER DECLARE THAT I SHALL ABIDE BY THE PROVISIONS OF THE SCHEME AS MAY BE IN FORCE FROM TIME TO TIME.
3. I FURTHER DECLARE THAT I HAVE NOT OPTED OUT FROM THE SCHEME IN ANY PREVIOUS OCCASION.(EXCEPT PRIOR TO 29/08/2011 CASES)

1/28/2020 9:23:01 AM Signature of the Applicant

N.B. Please take two copies of print out of the Application Form with scan photo & signature of all beneficiaries as
generated from the system to the DDO for verification.In case of a child below twelve years, natural guardian's scan
signature with child's photograph is required.