PUNJAB TEACHERS FOUNDATION (L2» SCHOOL EDUCATION DEPARTMENT SS) GOVERNMENT OF THE PUNJAB RAHMAN ARCADE, 36-E COURT STREET, LOWER MALL, Ss NEAR CIVIL SECRETARIAT PUNJAB, LAHORE. Phone# 042-99212497 ‘APPLICATION FORM FOR FINANCIAL ASSISTANCE FOR CANCER PATIENT (FOR ALL IN-SERVICE & RETIRED TEACHERS) Office use Only Instructions: Form No. 1. Personal Information should be filled in Capital Letters. 2. Only Properly filled / completed forms will be considered. 3. No Information should be left-blank. Name of Teacher: Recent Father's / Husband's Name: Picture CNLCH Date of Entry into Govt. Service: Designation: BPS, CcRoss aTTesTeD By Gazetted: Non-Gazetted HEAD OF INSTITUTION Retirement Date: Place of Present Posting: Place of Last Posting: Postal Address: Tehsil: Distt: Permanent Address: Contact Number! Stage T N M Tick () Relevant Stage ‘Staged Tr NO ie} Stage lh Tia NO. MO Stage 1B Tib NO- MO Stage IC Tic NO MO ‘Stage I 72 NO. MO Stage IIA Ta NO. MO. ‘Stage lib T2b NO. MO. Stage IMAL THT2 Ni MO) ‘Stage WAZ T3a TOXINOPNE MO Stage WB T3b NXINO/NE MO Stage IIIC T3¢ NX/NO/NT MO Stage W Any T Any N Mi Stage IVA ‘Any T Any N Mia tage VB ny T Any N MibThereby confirm & undertake that; [understand that if I consciously provide false information in this application, I will be ineligible for Financial Assistance. I will be responsible / bound to refund Financial Assistance to the Foundation Treasury. @ The details furnished in this application form are correct, complete & accurate and I have not withheld any information pertaining to the same. Dated. (SIGNATURE OF APPLICANT) Certified that all the entries have been checked and compared with original record. NAME OF HEAD OF INSTITUTE STAMP & SIGNATURE CERTIFICATE BY THE CEO (Edu.) / DEPUTY DIRECTOR (COLLEGES). Certified that Mr. /Mrs./.Mst. Designation___ ‘has patient.of Cancer. Hence his’/ her name recommended for Financial Assistance of Punjab Teachers Foundation. (COUNTERSIGNED) CHIEF EXECUTIVE OFFICER (Edu.)/ DEPUTY DIRECTOR (COLLEGES) Following attested documents should be attached alongwith application form. 1. test report of diagnostic centre / laboratory 2. Prescription of doctor during 1-1-2022 to 31-12-2022 3. Cancer stage certificate from authentic Hospital must be attached 4. Copy of Computerized National Identity Card. 5. Last pay slip. 6. Copy of Retirement Notification/P.P.0.No/ First Page of Pension Book.