GDS Healthcare Scheme reg:-

FORMAT FOR FURNISHING DETAILS IN C/W GDS HEALTHCARE SHCEME

Annexure – IV

Worker Name (GDS Name)
Caste
Minority (as per State List) indicate yes/no
Gender (indicate Male or Female)
Age
Father’s Name
Phone No.
Present Post held
Name of District
Mandal name Sub District or Tehsil or Taluka or block name may be given
Panchayat Name Panchayat Name in case of Panchayat Village or rural areas Or Ward No. in case of village where Gram Panchayat does not exist – Village name (No. of Ward) Or Name of Municipal Committee in vase of urban areas i.e. Name of Municipal Committee (MC) or Town Council (TC)
Village Name Village Name in case of rural areas Or Ward Number in case of Urban areas – Ward (No.)
Present residential address
Permanent residential address
Beneficiaries dependent details
SL.No.	Name	Age			Gender	Relationship with GDS
1
2
3
4
Date of regular appointment to the GDS Post :

This is to certify that the particulars mentioned above are true to the best of my knowledge and the beneficiaries dependent details mentioned above are only related to my members of family as defined in Rule 3(h) of GDS (Conduct and Engagement) Rules, 2011.

(Signature of GDS Beneficiary)

Dated …………………………