WAPDA MEDICAL DIRECTORATE 2 Colored awe MEDICAL REGISTRATION FORM - A Photographs Form No. New Registration Change Version, 8 Revised On 14:10.2015 4. Company / WAPDA WING. 2, Family-id (for office use onl 7 Regictration Statue SENG. No. (Contract, Regular, Retired, Widow, Deputation, Out Station) 3. employee's Name EBPs 7. Designation Birth Date 3. Joining Date 70, Last Posting Date Ti. Father's / Husband's 16, Facity 14 Family Gender’ 15. Marital Status re FacilityiCash Allowance) “7, Office Name (In case of retired or deceased employee last office Name) 18. Office Postal Address 49. Phone No. (with City code) 20, Pension Book No. 721, Retirement Date "22. Pension office Name 23. Pension office postal Address 724. Phone No. (with city code) 25. Home Address (Postal Address) 26. Phone No. (with city code) 27. Ema Adress: atjon/Application Date Signature (MS/DMS) Employee Signature Date of Retirement (In case of retired employee), Date of Death (In case of Deceased employee) Page: 112MEDICAL REGISTRATION FORM - B 2. Date of Birth] , aT, sr. 0, Dependant’ Namo Relationship C.NI.C No. o1 02 03, 05 oo. o7 08 ‘DECLARATION OF EMPLOYEE 7] desiare that neither my father nor my mother & a pensioner and he/she le not avaling Free Medical Facile / Cash Medical Alowance from any other institution. I declare that my vie/Husband is not avaing Free Mecical Facility Cash Medical Allowance from any other Institution | declare that the family members mentioned above are holy dependent upon me and siding with me, In case of any false devaration | may be dealt uncer relevant rules Employee's. nature ‘CERTIFICATE FROM CONCERNED OFFICE eae EE DED ‘Office Memo No Dated EPF NO. Code 11. This isto certify that the particulars given in this form are correct as per office record and employee's dependants information hhas been verified from Form-B issued by NADRA. ian. & Stamp Sign. & Stamp Drawing & Disbursing Officer Office Accounting Head (ln case of Retired / Deceased employee attestation from |LastiRetiring Office is required) TO BE FILLED BY THE WAPDA HOSPITAL “The employee whose particulars are given in this form is hereby allowed Medical Faciliies in accordance with WAPDA Medical Attendance Rules, Signature (MS/DMS) WAPDA MEDICAL CARD INFORMATION ‘33. Card No. | 34 Issued on | 35. Issued by (Name @ Signature) _ | 36. Received By (Name, CNIC No & Signature) ‘CHECKLIST OF DOCUMENTS TO BE ATTACHED. ‘Change of option from CMA to Medical Faciiy im case of BPS ( 1-15 ) issued from Drawing & Disbursing Oficer (in original) [Attested copy of CNIC of employee and his/her dependents raving | age of 18 years or above, 2 | Aitesied copy of Form-B issued by NADRAT Birth cerificates ofall | 5 children having age of 5-years or below. Nikat-Nama (where applicable) Nor-mariage and non employe decaraton Oh AO AGH vr ca of cash medica alovance orarewea 3] paper om empoyes fe she dughler having age above 25, | 7 | hpioyee his pton/Apleaton (nara) | Aitested copy of Pension Book of retired employee (family pension | g | Female married employees submit dependency and hook in casa of deceased employee) residing proof of her husband on non judicial paper Date. Received By Name and & Signature: Note: In case of change in the data / particulars new form duly verified from both Drawing & Disbursing Officer and Office Accounting Head may Ee furnished to concerned WAPDA Hospital / Dispensary to update the information. 2. Use extra sheet if required. Page: 2/2