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APPLICATION FORM FOR UPGRADATION OF ECHS SMART CARD FOR EXISTING MEMBERS CARD HOLDERS FILL UP ALL DETAILS IN BOLD LETTERS Pensioner/Family Pensioner Name Relationship Self/Spouse/Father/ Mother/Son/Daughter of Service No Rank Name Existing Card Regn No Force Army/Navy/Air Force/Coast Guard/DSC/SFF As applicable Date of Demise of pensioner In case of family pensioner only Details of member/ dependents - Ser No Member/ Dependent Name with address and tele No with STD code if different from existing one Parent Polyclinic required Latest Colour Photo Passport Size with Red background UID No if available Total cards demanded Payment Details DD No Date Amount Rupees Bank Name a Physical Disability b War Disability Yes Please attach relevant documentary proof Signature of Applicant black ink Applicants to retain photocopy of this form duly receipted by polyclinic/Stn HQ/Regional Centre. PTO In case any changes required to the existing details please specify eg change of parent polyclinic change of address and deletion of beneficiary due to death marriage over 25 age son employment etc* Changes required Reason The Cost of upgraded ECHS Cards will be paid Rs 135/- per card through DD in favour of dependent Note -1. Regional Centre ECHS War disabled/Battle casualty disabled veterans will be provided with white cards. The application alongwith DD in favour of dependent Regional Centre may be deposited at Polyclinic/Station HQ/Regional Centre. The new card s will be delivered at polyclinic where the forms were deposited* The old cards including add on card s will be required for activation of new cards and transfer of data* On successful activation the old card s will automatically be deactivated* The OIC Policlinic on activation of new card will destroy the old card and will render a certificate to this effect to dependent Regional Centre for updating the record. A proper record will be maintained at Policlinic to this effect. Incase of more than four members / dependants use additional sheet of this form*. PTO In case any changes required to the existing details please specify eg change of parent polyclinic change of address and deletion of beneficiary due to death marriage over 25 age son employment etc* Changes required Reason The Cost of upgraded ECHS Cards will be paid Rs 135/- per card through DD in favour of dependent Note -1. Regional Centre ECHS War disabled/Battle casualty disabled veterans will be provided with white cards. Regional Centre ECHS War disabled/Battle casualty disabled veterans will be provided with white cards. The application alongwith DD in favour of dependent Regional Centre may be deposited at Polyclinic/Station HQ/Regional Centre. The application alongwith DD in favour of dependent Regional Centre may be deposited at Polyclinic/Station HQ/Regional Centre. The new card s will be delivered at polyclinic where the forms were deposited* The old cards including add on card s will be required for activation of new cards and transfer of data* On successful activation the old card s will automatically be deactivated* The OIC Policlinic on activation of new card will destroy the old card and will render a certificate to this effect to dependent Regional Centre for updating the record.

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