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Guest Health Card Application

Amount: ₹50 for Individual Health Card

Payment Methods:

Note: Please upload payment slip/screenshot after payment

Personal Details

Full Name *

Father's Name *

Birth Date *

Gender *

Full Address *

District *

State *

Pincode *

Mobile Number *

Email Address *

Upload Photo * (Max 2MB, JPG/PNG)

Upload Payment Slip * (Max 5MB, JPG/PNG/PDF)