APPLICATION FOR ADMISSION INTO A.P.STATE EMPLOYEES GROUP INSURANCE SCHEME @@@@@@@ 01. Name of the Applicant : 02. Official designation : 03. Service to which attached. If on deputation, : state the parent department, Govt. also. 04. Service to which the applicant belongs : 05. Whether the post of the applicant is pensionable or not. : 06. Whether the applicant is permanent, temporary: or reemployed. If temporary, give the date of : commencement of service. : 07. Rate of emoluments drawn : PAY D.A. HRA 08. Scale of pay : 09. Rate of subscription per mensum : 10. If subscriber is subscribing to any other fund, : name of such fund 11. Whether or not the individual is compulsory or: COMPULSORY optional subscriber. : 12. Whether the applicant has a family or not : 13. Account No. to be allotted by the Accounts : Officer 14. Remarks : ........................................ Confirmed nomination in the prescribed form is duly filled in and enclosed. Station: Signature of the applicant Dated: Name: Designation: Address: Dated the ________ day of ________________________ (Month/Year) at ______________________________ (Place) Returned with Account Number allotted. This Number should be indicated in all correspondence relating to GIS. Signature of the Head of Institution
