ISLAMIA COLLEGE PESHAWAR

(Chartered University)
MEDICAL REIMBURSEMENT FORM
(To be filled in by the office)
No.___________________
Dated.________________
To
The Treasurer,
Islamia College Peshawar.
(Chartered University).

Subject: MEDICAL REIMBURSEMENT

I have spent a sum of Rs. 2189/- Rupees. Two Thousand, One Hundred & Eighty Nine Only
on the treatment of my self/wife/son/daughter/father/mother as per following breakdown.

S.No Cash Memo Nos. Dated Amount

1 256 15.03.2018 2189

Total 2189

Necessary cash memos along with respective prescription chits, original discharge card and photo
copy of the admission Treatment chart and intake output record of the patient duly attested by the Registrar
of the ward/RMO of the Hospital KTH are attached. I solemnly declare that the claim is correct and shall
be held responsible for disciplinary action on account of miss-statement of over claiming. It is requested
that re-imbursement as per rules may kindly be made to me.

Signature: ___________________________

Applicant Name: _____________________

RECOMMENDATION OF THE HEAD OF DEPARTMENT

Certified that the applicant is a permanent employee of the Islamia College University Peshawar and working
as Computer Operator under my supervision. The information as furnished above by him/her is correct.
The bills are forwarded for re-imbursement.

Head of Deptt: / Institution

No.____________
Dated.__________

N.B. 1. Dependence certificates in case of father/mother may be attached and photocopy of N.I.C of
applicant / dependence.

FOR USE OF ACCOUNTS SECTION

Registrar No._________________Page No.________________________ S.No.______________________

Funds under the Head The bills have been checked. A sum of Rs.___________ is permissible
Exist/don’t exit. Under the rules which may kindly be allowed.

Ledger Keeper Medical Asst: Supdt: Accounts

Sanctioned being within Rs.1000/- Sanctioned being within Rs.5000/- Sanctioned as above
Recommended for Sanction Recommended for Sanction

Dy. Treasurer Treasurer Vice-Chancellor