PAWAN HANS LIMITED ( WESTERN REGION ) DECLARATION CERTIFICATE For Medical Attendance ( 27/08/2022 to 27/08/2023 Employee No. A4400 It is hereby declared /certified that my below mentioned family members ,whose details are given below are normally residing with me and are wholly dependent on me, [st ‘Date of Birth | Age (Vrs) _| Relationship 1 “o-01-iqeq 33 | Sevt 2 [21-OFgp{ 30 | WEE ERS Ba a as fe 4 ne Ee = | inte | 5 = Benet oa It is also certified that I/we (self & spouse) will opt medical benefit from M/s Pawan Hans Limited ONLY and are not claiming medical benefit from any other organisation. Note: 1. Im case of Male dependent children above 21 years proof of his pursuing studies (i. certificate from School/College/Institute/University) would have to be furnished every ‘academic year. 2. Incase of Female dependent children(daughter) she should be unmarried. 3. Incase Spouse is working a declaration from their organisation stating that he/she is not availing any medical benefit from parent Company. Date: \% - 08-22. Signature: bh Name HAHORA Designation LT. Location: KAVORATIE.