AUTO GENERATED

Registration No : 0000400548
RECEIPT FOR DOCUMENTS CUM TEMPORARY RECEIPT EX SERVICEMEN CONTRIBUTORY HEALTH
SCHEME (ECHS)
Received documents from No 14564483HRank SepName SOUNDARARAJAN M towards
1.
application for membership of Ex-Servicemen Contributory Health Scheme (ECHS) :-
2. Pension Payment Order No (PPO No) (Attach photocopy) S/026536/1999
3. Category of Ward General
4. Force Type: Army 5. Regiment/Unit: 6 AOP JANSHI
Current Address with State and Pin
Permanent Address with State and Pin Code: Code:
NO 57 FIFTH STREET BANK STAFF COLONY, NO 57 FIFTH STREET BANK STAFF
6.
MADHAKKOTTAI ROAD, THANJAVUR, COLONY, MADHAKKOTTAI ROAD,
THANJAVUR, Thanjavur, Tamil Nadu , 613005 THANJAVUR, THANJAVUR,
Thanjavur, Tamil Nadu , 613005
8. DOB: 13
7. Mobile No: 9600254702 9. Date of Retirement: 31 Jul 1999
Jun 1965
10. Parent Polyclinic of Pensioner Thanjavur, MRO No. (if applicable)
11. Card Charges @ Rs. 177/- paid Rs. : 885 vide Transaction ID : IK00QFZAD3
12. Valid Upto : _________________

Primary Beneficiary Spouse Mother

Daughter Daughter

Name : Name : Name :

Name : NIRALI S Name : VAISHALI S
SOUNDARARAJAN M VIJAYAKUMARI S JAYALATCHMI M
DOB : 14 Oct 1997 DOB : 25 Feb 2001
DOB : 13 Jun 1965 DOB : 07 Oct 1971 DOB : 15 Jun 1943
Aadhaar No. : Aadhaar No. :
Aadhaar No. : Aadhaar No. : Aadhaar No. :
837391202506 786138740389
694248252551 411523951411 563215654794

13. ACTIVATION BY
Signature _________________
Place: _____________
(Stamp with Rank, Name &
Date: _____________
Appointment, OIC Parent Polyclinic)
Notes :-
This original receipt is required to be returned at the time of collection of Smart Card (s). Receipt will
1.
not be destroyed. This will be filed along with the original Application Form.
No Smart Card will be issued if this receipt in original is not produced and final verification by
2.
Central Org ECHS.
Record Office will retain this receipt after checking the Application Form till retirement of the
3.
individual
Stoppage of FMA and deposition of contribution (MRO) as applicable to be ensured prior to issue of
4.
this receipt to pre 01 Apr 2003 retirees by Regional Centre ECHS.
This receipt will be issued only on verification of original PPO and discharge book for old retirees
5.
who are not in possession of old Cards.
6. The Original Receipt is valid up to a maximum of SIX MONTHS from the date of issue.
7. Slip will be considered activated only after signatures of OIC Parent Polyclinic.
8. Aadhar verification to be ensured by Polyclinics.
9. Old cards/ temp receipts will be returned.

Date: 16 Jun 2018

Signature of ESM / Family Pensioner