ü¡ÙÛÉpp¡b£

ü¡ÙÛ ¡b£ Swasthya Bhawan,

ü¡ÙÛÉ J f¢lh¡l LmÉ¡Z cçl, f¢ÕQjh‰ plL¡l GN-29, Sec-V, Salt Lake, Bidhan Nagar,
Kolkata-91, West Bengal

FORM-B (Application for enrollment under Swasthya Sathi)

Application NO :
DISTRICT :
BLOCK/MUNICIPALITY:- MINORITY STATUS : YES/NO
PANCHAYAT/MUNICIPALITY:- DEPARTMENT:
VILLAGE/WARD:- CATEGORY:
RESIDENDIAL ADDRESS:- CAST:-
Name of Beneficiary:

Father’s Name:
OFFICE NAME &ADDRESS:-

RSBY URN(If Any):-

SL MEMBER NAME SEX AGE RELATION MOBILE NO. AADHAAR NO.(If Any) KHADYASATHI
NO ID NO.
1 Beneficiary
/Self
2

4
5

6
7

8
9
10

f¢lh¡-ll pLm pcpÉ-Hl e¡j ¢mM¤e

Ef­l¡š² abÉ pÇf¨ZÑ paÉ Hhw B¢j h¡ Bj¡l f¢lh¡­ll

-L¡e pcpÉ C¢af§-hÑ ü¡ÙÛÉp¡b£ L¡XÑ f¡C ¢e h¡ ü¡ÙÛÉp¡b£ L¡XÑ
Hl SeÉ gjÑ-¢h c¡¢Mm L¢l ¢e z
____________________________
SIGNATURE OF VERIFYING OFFICER

NAME:_____________________________ _________________________________
BENEFICIARY SIGNATURE

¢hnc S¡e-a 1800-345-5384 eð-l -k¡N¡-k¡N Ll-a f¡-le z

ü¡ÙÛÉ J f¢lh¡l LmÉ¡Z cçl, f¢ÕQjh‰ plL¡l phÑc¡C Bfe¡l f¡­n B­R z