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Application Form – Hospitalisation Scheme

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  • Application Form – Hospitalisation Scheme

APPLICATION/ENROLMENT FORM FOR PNB HOSPITALISATION

CONTRIBUTORY BENEFIT SCHEME FOR RETIRED EMPLOYEES

The Asstt. General Manager

For Office use only

Punjab National Bank

Personnel Admn. Division

Enrolment No._________

Head Office, 7 Bhikhaiji Cama Place

New Delhi.-110066

Please affix joint

photograph of self and

spouse

Please

enrol me as Member of the above scheme to which I hereby opt. I have gone

through the rules and regulations of the scheme and agree to abide by the rules and

regulations of the same as may be modified / amended from time to time . Particulars about

myself and my spouse are given below:

1. Name of Employee _______________________ 2. P.F No._______________

(In Block Letters)

3. Name of Spouse ________________________________________________

(In Block Letters)

4 Father’s/Husband’s Name________________________________________

(In Block Letters)

5. Date of Birth a) Self ______________ b) Spouse_______

____

6. Date of retirement ___________________

7. Type of Retirment :

(Attach documentary proof)

(i) Superannuation (ii) Medical Ground (iii) Demitted the office of GM

(iv) Dismissed (v) Compulsorily

retired (vi) Voluntarily retired under Officers’ Service

Regulations (vii) Voluntarily retired under Pension Regulations)

(viii) VRS under PNBEVRS 2000 (IX) Any other

8. Office from which retired _____________________________

Under CO____________________________

(Write the name) HO________________________

9. Date of joining the bank ___________________

10. Enrolment No. of old PNB Hospitalisation Contributory Benefit Scheme

for Retired Officers: _______________

11. Present Address ______________________________

(in Capital Letters) ____________________________

12. Permanent Address ___________________________

_____________________________

Mob.No._____________________Landline Phone No.________

13. I am enclosing herewith a Draft No. /CBS Cheque No. _______dated __________ for

Rs.5000/ – only favouring PNB Centenary Welfare Trust -A/C

PNB Hospitalisation

Contributory Benefit Scheme for Retired Employees

issued by the BO

_________________ _ (D. No _________ ) drawn on CDPC, New Delhi being my One

Time Subscription to the Scheme .

DECLARATION

(i) I have read and understood the PNB Hospitalisation Contributory Benefit Scheme

for Retried Employees and agreed to abide by the terms and conditions of HRD Circular No.

515 dated 19.02.2009.

(ii) The information given above by me is true to the best of my knowledge.

(iii). I also undertake that if at any point of time, during the currency of my membership

of the scheme, the information submitted by me, either in relation to application

form or hospitalisation claim preferred by me, is found to be false/misleading, my

membership to the scheme will be terminated without any notice to me. The amount

deposited by me towards my subscription of the scheme will stand forfeited and I

will not be eligible to become member of the scheme again.

(iv) I will inform the change of my address to the Bank immediately by Registered

Place_____________

_____________ _______________

SIGNATURE OF SIGNATURE /T.I .OF

RETIRED EMPLOYEE SPOUSE

15. It is certified that Shri/Smt..________________________ retired on

(date)________ from (Name of office)___________________________ as (Designation)

Signature of retired employee and signature/Thumb Impression of his/her spouse given above

are hereby verified.

_____________

(Authorised Signatory)

Circle/Head Office

P.A. No. ___________

NOTE:

1. Application form complete in all respects, must be sent to HO directly.

2. Strike off whichever is not applicable.