Directorate of Information and Publicity Government of NCT of Delhi Block no 9, Old Sectt Delhi-110054 Form for Health Card 1. Name of the Media Person (In capital letters) 2.Date of Birth 3.Residential address 4..Name and Address of the Organisation in which working 5. a) Press card number issued by DIP b) Valid upto 6.Details of the Dependents (See instructions below) Sl. No Name Date of birth Relationship with the card holder 7.Nearest Delhi government dispensary/ ____________________________ Hospital I hereby certify that the above information is correct and complete to the best of my knowledge and belief. I undertake to surrender the identity/Health card on my ceasing to be an accredited media person with the Government of Delhi. Signature of the Media person Checklist of documents to be attached: YES NO 1.Two passport size photographers. 2.Copy of the certificate regarding proof of date of birth of the dependent children mentioned at item no. 6 3.Certificate on the letter head of the organization and duly signed and stamped by the Office regarding reimbursement of the medial claim. Instructions 1. As per the Delhi Press Reporters Medical Aid Rules 1995, the dependent children below the age of 21 years are only entitled to avail the medial facilities with the Press card holder form Government of Delhi. The parents of the Press card holder having an income of not more than Rs. 1500 per month from all sources put together can also avail the facility. 2. Performa of Certificate to be given by the employee (item no.3 of checklist;) To whom so ever it may concern This is to certify that Shri/Smt//Km._______________________working in this organization as _______________________ has not claimed any medical benefit from this organization, for which she has submitted medical bills to Delhi Government, for reimbursement. Signatures of the Editor/Bureau Chief Office Stamp
