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Employer Declaration for EHS Health Card

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Md.Raziuddin Aslam
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2K views1 page

Employer Declaration for EHS Health Card

Uploaded by

Md.Raziuddin Aslam
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DECLARATION BY THE EMPLOYER

This is to certify that Sri/Smt/Mr/Ms. _________________________________

S/o/W/o/D/o____________________________ is working as_______________ since ________ years in

the office of ______________________ of Department ________________ with a pay grade of

______________

The following are the dependent beneficiaries of the concerned employees

[Link] Name of Date of Gender Relationship Maitalstatus(Married/Unmarried/ Aadhar


the Birth with Widow/Widower/Divorce number
Beneficiary Employee

Declaration of the Employee

I declare that the above information is true to best of my knowledge and submitting to Aarogyasri
Health Care Trust for issue of Healthcards under beneficiary. I am liable for disciplinary action for
declaring ineligible family member if any as Dependents.

Employee Signature

I certified that the above information is verified with office records and found correct

DDO/HOD/Controlling officer Signature with seal

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