NATIONAL FERTILIZERS LIMITED, VIJAIPUR UNIT

MEDICAL ADVANCE APPLICATION

1. Name of applicant :………………………………………….................................
2. Employee No. :……………………………………………………………….
3. Designation & Department :……………………………………………………………….
4. Name of the patient :……………………………………………………………….
5. Age of the patient/DOB :……………………………………………………………….
6. Relation of patient with Employee :……………………………………………………………….
7. Name & place of the Hospital :……………………………………………………………….
Where the patient is referred
8. Reference No. & Date :……………………………………………………………….
(Copy of Reference slip to be attached)
9. Estimated Expenditure :Rs……………………………………………………………
(to be supported with documentary evidence from the concerned hospital)
10. Amount of advance applied for :Rs.…………………………………………………………...
11. Whether any advance drawn earlier :Rs……………………………………………………………
against the same reference no., if any,
indicate the amount of advance
12. Nature of disease :………………………………………………………….……
13. Whether the patient is admitted in :……………………………………………………………….
thehospital(Yes/No)

Date Signature of Employee

RECOMMENDATION OF THE CHIEF MEDICAL OFFICER
Rs……………………… (in words)Rs………………………………………………………………….only
is sanctioned.

Sr. Chief Medical Officer

DGM(HR)