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FORM-B
(Application for enrollment under Swasthya Sathi)
DISTRICT:
*
-- Select District --
ALIPURDUAR
BANKURA
BIRBHUM
COOCH BEHAR
DAKSHIN DINAJPUR
DARJEELING
HOOGHLY
HOWRAH
JALPAIGURI
JHARGRAM
KALIMPONG
KOLKATA
MALDAH
MURSHIDABAD
NADIA
NORTH TWENTY FOUR PARGANAS
PASCHIM BARDHAMAN
PASCHIM MIDNAPORE
PURBA BARDHAMAN
PURBA MIDNAPORE
PURULIA
SOUTH TWENTY FOUR PARGANAS
UTTAR DINAJPUR
BLOCK/MUNICIPALITY:
*
-- Select Block/Municipality --
Block
Municipality
CATEGORY:
*
-- Select Category --
Other Backward Caste (OBC)
Others
Scheduled Caste (SC)
Scheduled Tribe (ST)
RESIDENTIAL ADDRESS:
*
PINCODE:
*
NAME OF THE APPLICANT:
*
HOF NAME (FATHER/SPOUSE):
*
DEPARTMENT (IF EMPLOYED):
OFFICE NAME & ADDRESS: (IF APPLICANT OR ANY MEMBER IS EMPLOYED)
DO ANY MEMBER OF THE FAMILY RECEIVE GOVT. SPONSORED HEALTH INSURANCE/ASSURANCE:
*
NO
YES
DO ANY MEMBER OF THE FAMILY RECEIVE MEDICAL ALLOWANCE FROM GOVERNMENT:
*
NO
YES
DO ANY MEMBER OF THE FAMILY RECEIVE MEDICAL ALLOWANCE FROM PRIVATE:
*
NO
YES
MEMBER(S) OF FAMILY ARE
Both Male & Female
All are Male
All are Female
Member List
SN
MEMBER ID
MEMBER NAME
RELATION
AGE
GENDER
AADHAAR NUMBER
KHADYASATHI RATION CARD NUMBER
EMPLOYMENT STATUS OF THE MEMBER
MOBILE NUMBER
EDIT
Delete
1
1
BENIFICIARY
0
Female
( * ) indicates All Fields are mandatory
Please update all fields
Check the family details in case any modification required please update that
If the member is not existing please delete that member
UPLOADED DOCUMENT(S)