Life Membership Enrolment

Application Details

To
The Secretary
Central Government Health Scheme Beneficiaries Association
20-A/C Bhattacharjee Para, Barrackpore, Kolkata - 700 120

Sir,

I am a CGHS Card Holder and like to be a member of the CGHS Beneficiaries Association. My relevant details are given below.

I shall abide by the Rules and Regulations of the Association.

Thanking you,

Date:

Yours faithfully

CGHS Card Information

CGHS Card Number *

Name of Dispensary *

Personal Information

Name (In Capital Letters) *

Phone / Mobile Number *

Address *

Blood Group

Date of Birth *

Service Status

Employment Status

Name of the Central Government Office *

No. of CGHS Beneficiaries *

Other Beneficiary Details

Beneficiary 1

Other Beneficiary Name

Other Beneficiary Card Number

Beneficiary 2

Other Beneficiary Name

Other Beneficiary Card Number

Beneficiary 3

Other Beneficiary Name

Other Beneficiary Card Number

Beneficiary 4

Other Beneficiary Name

Other Beneficiary Card Number

Member Photograph

Upload Photograph (Optional)

Photograph is optional. You may submit the application without uploading any photograph.
If you upload a photograph: JPG, PNG or WEBP format is allowed.
Maximum file size: 2 MB.

Membership Fee Payment

Please make the payment of Membership Fees and enter the Transaction ID below.

Scan the QR Code to make payment

Payment Transaction ID

Important: Please verify all information before submitting the application.
Photograph is optional. You may submit the application without uploading an image.
If you choose to upload a photograph, it must be a valid JPG, PNG or WEBP image and should not exceed 2 MB.

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Central Government Health Scheme Beneficiaries Association

Regd. Under W.B. Societies Act

LIFE MEMBERSHIP ENROLMENT FORM