Medical Reimbursement Form

(This form will help us reimburse your medical expenses .We will make payment by cheque
in your name which will be mailed by post at the address mentioned by you. This process
will typically take fifteen days of time)

1. Department : ( Interviewed for) _________________________________________

2. Name (as spelled in the bank account ):

(Please leave a blank space between first name, middle name and last name)
(We do not require your bank account number since payment will be made by
cheque )

3. Date Of Medical Test: _______________________________

4. Medical Test Details:

Full Medical Test

Only Eye Test

5. Address:

(Please mention the address where you want your cheque to be delivered with Pin
code and Phone number below)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
Total amount: _____________________________

Signature: __________________ Date:

_______________________