WFHS Family Health Discount Card

Charitable Trust (Reg No.) SunTower Building, 4th Floor, East Fort, Thrissur, 680005

Online Application Form For availing WFHS Family Health Discount Card

Name of card applicant :

Photo of Applicant:

File:

Gender / Sex

Male

Female

Age :

(Date/Month/Year)

Photo ID Number:

(Photo ID number of any one of the following documents of Aadhar Card / Pan Card / Voters Id / Passport/ OCI Card / driving Licence)

Address of card applicant :

Pin code:

Phone Number :

Mobile Number :

Email Id :

Type of card entitled: Silver Gold Platinum

Name of Spouse :

Age :

Date/Month/Year :

Name of the father of card holder :

Age :

Date/Month/Year :

Name of the mother of card holder :

Age :

Date/Month/Year :

Name of the father of spouse :

Age :

Date/Month/Year :

Name of the mother of spouse :

Age :

Date/Month/Year :

Name of Handicapped / Adopted / any Dependent :

Age :

Date/Month/Year :

Name of Widow / Divorced Daughter :

Age :

Date/Month/Year :

Dependent Son below 25 Years / Unmarried Daughter / Widow and Divorced Daughters Dependents below 25 Years Son / Daughter

1. Name Son /Daughter :

Age :

Date/Month/Year :

2. Name Son /Daughter :

Age :

Date/Month/Year :

3. Name Son /Daughter :

Age :

Date/Month/Year :

4. Name Son /Daughter :

Age :

Date/Month/Year :

5. Name Son /Daughter :

Age :

Date/Month/Year :

Name of the Nominee for availing Accidental Death Insurance amount :

Age :

Date/Month/Year :

Any Photo ID Number:

Relation of card applicant with nominee:

I with Aadhar card/ Voters ID/ Passport number/BPL card/APL card/Driving License/OCI card/NorkaCard hereby declare that details given about my family members above is true with best of my knowledge. If I have given any false photo id number, I will not be eligible for availing accidental death/permanent disability amount from insurance company and I will not be entitled for availing discount rate treatment from hospitals and other centres. WFHS trustees responsibility is to observe whether card holder are getting discount. WFHS trust official are not liable at all as joinly and severely for the dissatisfaction for the treatment received from selected hospitals and in settling the hospital bills. For inpatient treatments hospitals are fully responsible. I am signing the above application after fully understanding all the conditions.

For your safety, all transactions onlythrough bank.

No cash transaction, except cash payment at WFHS office and will receive a cash receipt.

Any outside cash transaction, WFHS officials are not responsible.

Pravasees remittance for availing card only from NRE/NRO Indian Rupee account. Foreign currency is not acceptable.

Receipt for payment will be send by post along with card.

While making donations, Pan Card Details is mandatory.

Payment made to receive card, while donating Dialysis Kit, One Day One Meal Donations, details to be send along with application form or send to us by Post/ Email/Whatts App.

Online Application Form For availing WFHS Family Health Discount Card

WFHS Family Health Discount Card

Charitable Trust (Reg No.) SunTower Building, 4th Floor, East Fort, Thrissur, 680005

Online Application Form For availing WFHS Family Health Discount Card

SELF DECLARATION

FOR MAKING PAYMENT

Upload any two specified documents