Form AA ce LL GOVERNMENT HEALTH SCHEME Application Form for renewal of CGHS card (serving employees) ‘Name of the applicant: Mohammad Nawab CGHS Card No. ee Name of the DepartmentOffice: Narcotics Control Bureau, Khodiyar, near Sardardham Ahmedal Pay Band: 2(Level-It) Pay in Pay band (excluding Grade Pay):Rs. 67700-208700 Grade Pay: Rs. a Designation: Assistant Director Ward Entitlement: Private Ward Contact No: 9452091877 Residential Address: (1) Rio NCB, Khodiyar, Near Vaishnodevi Circle Ahmedabad Pin code: 382421 (2) Permanent Address: 115 Chak, Post Bahadurganj, Prayagraj (U.P.) Pincode:211003 6._Details of Family: Photo [Name Mohammad Nawab Mrs. Gudiya Km. Ayreen Fatima Relationship Ser Wife Daughter | Date of Birth | 01/05/1967, 0470471979 13/11/2001 Photo kw and | Name Mohammad Rehan Mohammad Farhan | Relationship Son Son | Date of Birth 27708/2004 10/06/2012 DECLARATION ‘hereby declare that the statements made above are true and that the persons included dependent on me and that no information has been concealed or has been misrepresented the details of family are wholly and I stand Dated FOR OFFICIAL USE : . furnished by the applicant has been veri are being deducted every month from the salary of the applicant, The inform: Name of the Sponsoring authority/office Dated: nature (with seal) Tel No, IMPORTANT he with the application form) vorothe, Setfatested photocopy of od C6 ort filing be eneloned fh) A copy, cards should be. ‘etal of family. iy ‘ofthe can Detnition of fami ly under CCHS shouldbe the diy eerticae be attached, iCOR cae imo CENTRAL GOVERNMENT HEALTH SCHEME m™ MOHAMMAD NAWAB 4453753 - uffa/ Service wrafaft: / Date of Birth: 01/05/1967 wef / Blood Group: - = eis aun / Valid Upto: Feb 2025 9 wrvimamnsas uit eet Bt fate /Date of issue: Mar 2020 Nm Se °18890327300044537533 frees / Directore OTT ATHIT HIZns AAs Mohammad Nawab 8165 0059 1635 8 Fy ara — arr aercett BT HTceppeprerutatere res aat: S/O: atta HeHe, 115-7%, Address: s/O: Khalil Anmad, agree, are oTH FTA, TATBTATS, 415-Chak, Bahadurganj, Near zarrare PAS, TATSTATS, SAK TAT, Modi park, Allahabad **, 211003 Allahabad City, Allahabad, Allahabad, Uttar Pradesh, 211003 s bX) 1947 h dai 1800 180 1947 e\p @uidai.gov.in AA www.uidai.gov.infer Date of RAFU Retation 6 90 oh cen Reread & arena Pot seca aay Plastic Card and valid for treatment in CGHS REA TET A FE TF /Please Chee the d. fhat net : ‘num / Vaid Upto: Feb 2025 er Yh tne /oate of wave: Mar 2020 | as freee / DirectorController : PAO(CISF),MHA.Navi Mumbai Employee Name Designation : Assis Assistant Director, DDG (WR), NCB Employee Code : 32 Salary Month : Januar poleraie Basic Pay : 85800 ee Bank Alc No : XXXXXXXXS979 — Emotiments 1A ~ Govt. Recoveries SS ——Von Govt Recoveries — | Particulars | Amount (Rs.) Particulars | Amount(Rs.) | Inst.No. | Particulars | Amount (Rs) | Inst No Basic/Oft. Pay '85800| Prof Tax 200 DA 45474] CGEGIS 120 | HRA 25740|GPF_GR_ABC 30000 TPT Allow 11016) Income Tax 68105 cGHs 650 | Heal_ Edu 2724 Comp Adv (Prin) 1000 200 | | ‘Total Emolument 168030| Total Govt. Recoveries 702799 “Total NG Recoveries 0 | "Net Pay . 65231 (Sixty Five Thousand Two Hundred Thirty One only) el | ‘Voucher No | V14322 Voucher Date: 28-01-2025 Signature GENERATED FROM THE DATABASE wheeerr were / wear /anatatant directs¥/DDO ee, eH, A, (2 a), SEHRTTET CB (WH) Ademedadod